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A    TREATISE    ON    PLAGUE 


CAMBRIDGE   UNIVERSITY   PRESS  WAREHOUSE, 

C.   F.   CLAY,   Manager. 

ilontion:    AYE   MARIA  LANE,   E.G. 

AND 

H.   K.    LEWIS, 
136,    GOWER    STREET,    W.C. 


MJi^Mi 


50,   WELLINGTON  STREET. 
Ueipjig:   F.  A.  BROCKHAUS. 
^etx>   ©ork:    THE   MACMILLAN   COMPANY. 
BombatJ  anU  Calcutta:  MACMILLAN  AND  CO..  Ltd. 


[-1//  rights  reserfed\ 


A 

TREATISE    ON    PLAGUE 

dealing  with  the   Historical, 

Epidemiological,   Clinical,  Therapeutic 

and   Preventive  aspects  of  the 

Disease 


by 
W.   J.    SIMPSON, 

M.D.  Aberd.,  F.R.C.P.  Lond.,  D.P.H.  Camb. 

Professor  of  Hygiene,   King's  College,   London  ;    Lecturer  on  Tropical   Hygiene, 

London  School  of  Tropical  Medicine  ;    formerly  Health  Officer,  Calcutta  ; 

Medical  Adviser  to  the  Government  of  Cape  Colony,  during  the 

Outbreak  of  Plague  in  1901  ;    Commissioner  for  the  Colonial 

Office  to  Inquire  into  the  Causes  of  the  Continuance  of 

Plague  in  Hongkong 


Cambridge: 

at  the  University   Press 

1905 


Cambrttigc : 

PRINTED    BY    JOHN    CLAY,    M.A. 
AT    THE    UNIVERSITY    PRESS. 


Lifcfiiy 

set) 


TO   ALL   THOSE 

WHO   ARE   ACTIVELY   INTERESTED   IN   PLAGUE 

AND   ITS   PREVENTION   THE   AUTHOR   DEDICATES 

THIS   WORK 


7S2G47 


PREFACE. 

THIS  volume  has  been  written  at  the  request  of  the  Syndics  of  the 
Cambridge  University  Press  with  the  object  of  bringing  within 
a  moderate  compass  the  principal  facts  concerning  plague,  from  its 
historical,  epidemiological,  clinical,  therapeutic  and  preventive  aspects. 
Eleven  years  ago,  plague  as  an  epidemic  disease  was  merely  of  historical 
interest.  Confined  to  some  remote  places  in  China,  in  India,  in  Persia, 
in  Arabia,  and  in  Africa,  its  power  was  generally  believed  to  be  extinct. 
To-day  plague  is  a  matter  of  concern  to  many  countries  and  has  been 
the  subject  of  two  International  Conferences.  These  Conferences  have 
met,  discussed  and  agreed  to  the  carrying  out  of  measures  which,  while 
inflicting  the  least  injury  on  commerce,  might  reasonably  be  expected 
to  protect  Europe  from  an  invasion  of  the  disease,  and  during  the  past 
eight  years  Europe  has,  notwithstanding  one  or  two  alarms,  had  little 
reason  to  doubt  that  the  adoption  of  these  measures  has  been  most 
serviceable  in  preventing  the  permanent  lodgement  of  plague.  Europe 
is  however  but  a  small  part  of  the  world  and  other  continents  have  not 
been  so  fortunate,  and  although  no  great  outburst  has  occurred  on  the 
American,  African,  or  Australian  Continent,  yet  there  remains  the  fact 
that  the  disease  has  acquired  a  lodgement  in  these  and  necessitates  the 
greatest  vigilance.  Plague  takes  its  own  time  and  opportunities  for 
its  development,  and  it  is  unwise  to  be  lulled  into  a  sense  of  security 
by  its  apparent  impotency  to  spread  in  a  particular  country.  That  it 
is  capable  of  spreading  is  seen  too  plainly  in  India.  Few  thought 
it  possible,  when  plague  broke  out  in  Bombay  in  1896  after  an  ab- 
sence of  200  years,  that  the  disease  would  not  be  controlled,  checked 
and  stamped  out  in  a  short  time.  It  was  a  rude  awakening  when  the 
deaths  began  to  mount  up  to  a  few  thousands  to  find  the  old  scenes 
associated   with   plague    ei)idemics    reappear.     The   closed   houses,   the 


viii  Preface 

deserted  streets,  and  nearly  half  of  the  population  of  Bombay  fleeing 
panic-stricken  from  the  city,  testified  to  the  fact  that  plague  had 
lost  none  of  its  old  terrors,  and  recalled  the  condition  of  affairs  described 
in  the  old  epidemics  of  plague.  Later,  when,  owing  to  the  decline  of 
the  epidemic,  confidence  was  restored  and  the  people  had  in  consequence 
returned,  there  were  congratulations  as  to  the  lightness  of  the  attack 
compared  with  the  mortality  in  the  great  epidemics  of  the  past,  yet, 
the  next  year  and  every  year  since  1896,  the  disease  has  recrudesced 
in  the  city  of  Bombay,  and  the  number  of  deaths  is  fast  mounting  up 
beyond  the  mortality  of  any  epidemic  of  plague  in  any  single  city  in 
the  past  with  the  exception  of  those  of  Constantinople  and  Grand  Cairo. 
And  still  the  disease  continues.  Plague  has  moreover  spread  from 
Bombay  to  the  Bombay  Presidency,  and  from  the  Bombay  Presidency 
to  a  large  portion  of  India.  Slow  in  its  progress  it  has  steadily 
advanced ;  and  now  the  30,000  deaths  from  plague  which  occurred 
in  India  in  the  first  year,  and  which  created  so  much  alarm,  has  reached 
during  the  past  two  years  over  three-quarters  of  a  million  per  annum. 
In  1903  the  number  of  deaths  from  plague  in  India  was  853,000,  and 
in  1904  it  was  over  a  million,  being  1,040,429.  Of  the  million  deaths 
in  1904,  over  350,000  occurred  in  one  Province.  The  Punjaub  is  not  a 
large  Province  ;  it  has  a  population  of  under  27  millions  \  or  less  than 
that  of  England,  and  yet  it  lost  in  the  course  of  12  weeks  in  1904  over 
a  quarter  of  a  million  of  its  inhabitants.  If  in  the  Province  of  Manchuria 
either  the  Russian  or  Japanese  army  now  opposed  to  one  another  were  by 
some  misfortune  completely  destroyed,  the  catastrophe  would  not  be 
greater  than  what  happened  to  the  inhabitants  of  the  Punjaub  from 
plague,  and  if  both  armies  were  destroyed  it  would  not  compare  with 
the  destruction  of  human  life  from  this  disease  in  India  in  1904.  These 
are  the  official  figures,  and  are  admitted  to  be  below  the  mark  on  account 
of  concealment  on  the  part  of  the  inhabitants.  The  total  number  of 
deaths  in  India  officially  recorded  fi:-om  plague  since  1896  was,  up  to  the 
end  of  December  1904,  three  millions  one  hundred  and  fifty  thousand. 

Figures  give  a  very  inadequate  representation  of  the  amount  of 
misery  which  plague  has  brought  and  is  continuing  to  bring  to  India. 
Medical  men  and  other  workers  engaged  in  plague  epidemics  may  have 
some  conception  of  its  intensity  when  they  see  whole  families  swept 
away  by  the  disease,  but  for  most,  and  for  those  outside  its  sphere,  it  is 
difficult  to  realise  the  full  extent  of  suffering  and  desolation  that  has 

1  Census  of  India  l!l01  gives  26,880,217. 


Preface  ix 

befallen  hundreds  of  thousands  of  families  in  India  and  threatens  the 
homes  of  hinidreds  of  thousands  more. 

This  plague  is  for  India  a  grievous  calamity;  none  the  less  grievous 
because  it  is  borne  with  that  wonderful  fortitude  and  patience  so 
characteristic  of  the  people  of  Hindustan,  nor  is  it  limited  to  the 
physical  pain  and  mental  grief  in  each  home,  great  as  they  are. 
Scarcity  of  labour  and  loss  of  trade  are  beginning  to  be  felt  in  the 
provinces  worst  affected,  and  it  is  not  surprising  that  in  the  Indian 
papers  fears  are  expressed  that  if  there  is  no  abatement  of  the  disease, 
portions  of  the  country  may  have  to  face  "the  possibility  of  large  areas 
of  land  unfilled,  of  trade  and  commerce  decaying,  because  the  popula- 
tion has  died  or  fled  carrying  the  disease  to  districts  hitherto  un- 
affected •."  In  fact  if  the  plague  continues  its  ravages,  as  it  has  every 
appearance  of  doing,  it  will  more  slowly  but  as  surely  produce  the 
same  conditions  in  India  as  it  did  in  times  past  in  Europe  in  the 
earlier  pandemics.  A  statement  like  this  will  come  as  a  surprise  to 
most  people,  for  in  the  newspapers  in  England  there  appear  weekly 
bulletins  from  Hongkong  and  the  Mauritius  giving  the  number  of 
deaths  fr-om  plague  in  the  colonies  in  the  plague  season.  The  figures 
never  mount  up  to  more  than  a  hundred  deaths  a  week  at  the  most  and 
seldom  to  half  that  number.  The  impression  produced  by  these  bulletins 
is  that  they  represent  the  total  extent  of  plague  in  the  English 
dominions,  and  the  statement  that  in  the  epidemic  season  plague  carries 
off  its  victims  in  India  at  the  rate  of  thirty  or  forty  thousand  a  week 
is  received  with  incredulity.  When  it  is  found,  however,  to  be  true, 
most  of  those  who  hear  it  are  appalled  at  the  condition  of  affairs  affect- 
ing our  greatest  dependency,  for  whose  welfare  England  is  responsible 
and  anxious  to  do  everything  in  its  power  to  maintain  in  a  state  of 
happiness  and  prosperity. 

Adverse  critics  are  to  be  met  with  who  view  the  ravages  of  plague 
as  a  blessing  rather  than  as  an  evil  to  be  overcome  by  every  means 
possible,  wh(jse  contention  is  that  plagues  are  necessary  and  are  Nature's 
methods  of  keeping  down  an  enormous  population  that  would  otherwise 
perish  by  hunger.  It  is  an  easy-going  doctrine  and  saves  trouble  to 
those  unaffected.  It  is  the  reproduction  in  a  more  subtle  form  of  an 
old  doctrine  held  many  centuries  ago,  and  which  makes  strange  reading 
for  those  imbued  with  the  trend  of  thought  of  the  20th  century.  In  the 
seventh  century,  according  to  the  records  of  the  Church  of  Mayo-,  two 

'  Leading  article  entitled  "  I'hi^ue  administration,"  Pioneer  Mail,  .June  IVtli,  1904. 
-  A  Histori/  of  Epidemic  Pcstilnire^.     ISy  Edward  Basoonibc,  M.D.,  1851. 

S.  b 


M 


X  Preface 

kings  of  Erin  suninioncKl  the  ju'incipal  clergy  and  laity  to  a  council  at 
Teniora,  in  conseijuonce  of  a  general  dearth,  the  land  not  being  sufficient 
to  support  the  increasing  population.  The  chiefs  (mdjoj^es  populi) 
decreed  that  a  fast  should  he  observed  both  by  clergy  and  laity  so 
that  they  might  with  one  accord  solicit  God  to  prai/er  to  remove  hy 
some  species  of  pestilence  the  hartliensome  inidtitndes  of  the  inferior 
people,  "  Omnes  majores  petebant  ut  niniia  nuiltitudo  vulgi  per  in- 
hrniitateni  alicpiani  tolleretur,  quia  numerositas  populi  erat  occasio 
faniis."  St  Gei'ald  and  his  associates  suggested  that  it  would  be 
more  conformable  to  the  Divine  Nature  and  not  more  difficult  to 
multiply  the  fruits  of  the  earth  than  to  destroy  its  inhabitants.  An 
amendment  was  accordingly  moved  "  to  supplicate  the  Almighty  not 
to  reduce  the  number  of  the  men  till  it  answered  the  quantity  of  com 
usually  })roduced,  but  to  increase  the  produce  of  the  land  so  that  it 
might  satisfy  the  wants  of  the  people."  However,  the  nobles  and  clergy, 
headed  by  St  Fechin,  bore  down  the  opposition  and  called  for  a  pesti- 
lence on  the  lower  orders  of  the  people.  According  to  the  records 
a  pestilence  was  given,  which  included  in  its  ravages  the  authors  of 
the  petition,  the  two  kings  who  had  summoned  the  convention,  with 
St  Fechin,  the  king  of  Ulster  and  Munster  and  a  third  of  the  nobles 
concerned.  Another  and  similar  account  of  this  incident  is  given  in 
the  doings  of  the  Saints  of  Ireland  ^ 

Other  critics,  bearing  in  mind  the  op})osition  and  hostility  with  which 
the  preventive  measures  introduced  by  the  Government  of  India  in  the 
early  days  of  the  epidemic  were  met  by  the  people,  emphasise  the 
political  dangers  which  are  likely  to  arise  from  any  action  and  which 
justify  the  present  policy  of  leaving  things  alone  and  only  assisting 
when  aid  is  desired.  The  force  of  this  argument  must  always  be  given 
due  weight  when  dealing  with  the  people  of  India,  whose  mode  of 
thought  is  different  from  that  of  the  West.  But  while  admitting  this, 
the  fact  must  not  be  lost  sight  of  that  hostility  was  largely  engendered 
by  the  methods  adopted,  owing  firstly  to  the  absence  of  an  organised 
sanitary  service  and  the  consequent  employment  of  agencies  for  the 
inspection  of  houses,  repugnant  to  the  feelings  of  the  people,  and 
secondly  because  of  a  lack  of  knowledge  of  the  channels  by  which  the 
disease  spreads  and  the  consequent  futility  of  the  methods  adopted  at 
much  cost  and  effort  for  the  prevention  of  the  disease.  The  lack 
of    an    organised   sanitary   service   and    the    lack   of    knowledge   still 

^  Acta  Sanctorum  Hiherniae.     Tom.  i.  p.  COl.     Lovanii,  164-5. 


Preface  xi 

remain,  and  if  hope  is  to  come  to  India  it  must  be  by  their 
removal.  It  cannot  be  beyond  the  power  of  statesmanship  to  seek 
means  for  averting  and  ameliorating  the  sufferings  of  India,  and  yet  to 
do  so  successfully  without  raising  dangers  to  the  well-being  of  the 
community  or  of  the  Government.  Even  those  who  see  necessity  for 
caution  in  the  methods  of  working  to  save  the  people  from  dying  of 
plague  in  the  epidemic  season,  would  probably  not  object  to  active 
measures  of  prevention  during  the  period  of  quiescence  of  the  disease, 
when  there  is  no  alarm  or  tendency  to  panic.  These  anticipatory 
measures  could  easily  be  carried  out  without  friction  if  suitable 
machinery  were  there.  Elsewhere*  I  have  shown  the  nakedness  of 
India  in  sanitary  organisation,  and  its  inability  under  present  conditions 
to  defend  itself  against  epidemics  of  any  kind.  It  has  no  thoroughly 
trained  and  fully  equipped  sanitary  army  made  up  mostly  of  its  own 
people  familiar  with  the  ways  of  its  inhabitants.  It  is  now  over  ten  3'ears 
since  this  defenceless  state  was  shown  to  exist,  and  a  scheme  sketched  out 
for  the  organisation  of  a  service  for  the  prevention  of  disease.  Is  it  too 
much  to  suggest  that  some  portion  of  the  large  annual  surpluses  of 
money,  which  India  is  now  obtaining  by  its  fiscal  policy,  shall  be  devoted 
to  this  important  object  ?  The  maintenance  of  a  well-trained  native 
sanitary  service  to  protect  the  people  of  India  dying  from  preventable 
disease  is  as  feasible,  and  from  a  humane  point  of  view  as  important, 
as  the  maintenance  of  a  well-organised  native  army  to  protect  the 
country  against  an  external  enemy.  It  is  to  be  hoped  that  for  the 
sake  of  India  an  organised  Public  Health  Service  commensurate  with 
the  requirements  of  the  country  will  be  created. 

The  formation  and  development  of  a  trained  sanitary  service,  with 
which  qualified  women  should  be  associated,  will  not  be  sufficient  to 
meet  the  conditions  now  existing.  There  is  urgent  need  for  systejnatic 
and  scientific  study  of  the  disease.  More  requires  to  be  known  concerning 
the  mode  of  spread  of  the  disease  in  India,  and  of  the  conditions  which 
fovour  its  continuance  during  the  non-epidemic  periods.  On  a  proper 
understanding  of  these  depend  many  of  the  preventive  measures.  If 
rats,  insects,  fleas,  and  infected  clothes  are  the  chief  factors  in  the  dis- 
semination of  the  disease,  there  is  little  need,  unless  it  be  for  pneumonic 

1  "The  Need  of  a  Sanitary  Service  for  India."  By  W.  J.  Simpson,  M.D.  Tranxactions 
of  the  First  Indian  Medical  Congress,  1894,  and  Indian  Medical  Gazette,  Dec.  18'J5. 

"Plague  in  India."    British  Medical  Journal,  1898. 

"An  Address  on  Preventive  Work  in  the  Tropics  to  the  Eoyal  Institute  of  Public 
Health."     By  W.  J.  Simpson,  M.D.     Lancet,  1904, 

62 


xii  Preface 

plague,  of  resorting  to  isolation  in  liDspital  and  segregation  camps, 
which  is  opposed  to  the  feelings  of  Hindus  and  Mahonniiedans 
alike.  If  contaminated  food  is  an  important  fjictor  in  the  pro- 
duction of  plague,  measures  to  secure  purity  should  bo  introduced. 
But  all  these  have  to  be  proved  for  India.  Seven  years  of  golden 
opportunities  have  passed  unutilised.  If  the  first  18  months  in  which 
scientific  study  and  research  partly  carried  out  by  a  scientific  committee 
in  India  and  partly  by  foreign  commissions  be  excepted,  no  real  and 
sustained  efforts  commensurate  wdth  the  great  issues  at  stake  have 
been  made  to  get  to  understand  the  disease  and  the  manner  in 
which  it  spreads,  and  no  facts  of  practical  value  for  the  prevention  of 
plague  have  come  from  India.  It  seems  to  have  been  considered  a 
waste  of  money  to  spend  20,000  or  80,000  pounds  in  studying  the 
disease  and  its  prevention,  though  twice  or  three  times  that  amount 
is  but  a  small  fraction  of  the  vast  sums  spent  for  the  most  part 
uselessly  on  administrative  and  executive  methods,  which,  effective 
enough,  perhaps,  in  a  coimtry  with  a  fully  equipped  sanitary  service 
and  when  rigorously  carried  out  at  the  commencement,  have  proved  to 
be  in  India  with  its  conditions  of  no  avail. 

For  preventive  work  much  more  light  is  needed  on  a  subject 
involved  in  obscurity,  and  this  can  only  be  obtained  by  scientific  research 
which  shall  be  regular  and  systematic  in  its  nature  and  which  shall  be 
closely  associated  with  a  skilled  and  special  organisation  devoted  to 
plague  administration  and  which  shall  not  be  confined  to  laboratory 
experiments.  Plague  requires  scientific  investigation  outside  as  well  as 
inside  the  laboratory.  Research  and  administration  in  this  matter 
need  to  go  hand  in  hand.  Each  if  worked  on  its  own  lines  without 
reference  to  the  other  will  accomplish  but  little,  and  that  little  is  not 
likely  to  be  of  much  practical  value.  In  a  disease  such  as  plague  the 
efforts  of  a  sanitary  service  are  only  likely  to  be  successful  when 
directed  into  the  proper  channels  by  its  close  association  with  scientific 
research  both  in  the  laboratory  and  in  the  locality  affected. 

It  is  unnecessary  to  dwell  on  the  danger  of  the  disease  spreading  to 
other  countries  or  of  the  serious  risk  attendant  on  plague  being  allowed 
to  spread  wdthout  understanding  the  methods  by  w^hich  this  happens. 
An  optimistic  opinion  prevails  that  the  disease  will  not  spread  and  soon 
die  out  in  India.  This  view  has  been  strenuously  held  ffom  the  first 
and  the  continuance  of  the  plague  with  its  three  milli(jn  deaths  has 
been  a  .source  of  disappointment  in  this  respect.  Doubtless  if  held  long 
enough  this  view  will   ultimately  jjrove  true,  but  it  may  not  be  in  this 


Preface  xiii 

generation.  This  dying  out  and  failure  to  spread  are  not  in  accordance 
with  the  history  of  plague  in  the  past  when  it  has  acquired  such 
dimensions  as  those  existing  in  India,  and  there  is  nothing  so  far  as  may 
be  judged  in  the  present  condition  of  the  world  fjr  it  to  act  differently 
now  than  formerly.  On  the  contrary,  with  war  in  the  East,  with  grave 
economical  and  political  disturbances  existing  at  present  and  with 
unusual  seasons,  the  conditions  which  in  earlier  times  favoured  the 
prevalence  of  plague  do  not  appear  to  be  altogether  wanting  for  its 
expansion  in  the  present  age.  Whether  history  will  repeat  itself  or 
not  or  whether  the  risk  of  extension  to  neighbouring  countries  is  great 
or  small  remains  for  the  future  to  decide.  No  one  can  prognosticate 
one  way  or  the  other.  But  amidst  this  uncertainty  there  is  one  thing 
absolutely  certain,  and  it  is  that  owing  to  this  invasion  of  plague  the 
condition  of  the  people  of  India  in  the  worst  affected  provinces  is  most 
deplorable.  It  not  only  claims  the  deepest  sympathy,  but  also  in  the 
interests  of  humanity  imperatively  demands  the  closest  attention  and  the 
adoption  of  suitable  and  adequate  remedial  measures  for  its  amelioration 
and  for  combating  the  spread  and  ravages  of  the  disease. 

In  conclusion  a  pleasant  duty  devolves  on  me  to  acknowledge 
with  grateful  thanks  the  kindly  assistance  given  me  in  writing 
this  book.  My  acknowledgements  are  due  to  the  Syndics  of  the 
Cambridge  University  Press  for  the  facilities  they  have  afforded  me  in 
its  publication.  They  are  also  due  to  Dr  Norman  Moore  and  Dr  Joseph 
Frank  Payne  for  assistance  and  advice ;  also  to  Mr  W.  M.  Hafifkine, 
C.I.E.,  for  his  microscopical  specimens  of  involution  forms  of  plague 
bacilli.  It  is  impossible  to  over-estimate  the  splendid  services  which 
have  been  rendered  to  India  by  Mr  Hafifkine  by  his  discoveries  of  a 
cholera  and  plague  prophylactic,  and  by  his  work  carried  out  in  India 
amidst  great  ditficulties  in  connection  therewith.  Such  services  can 
never  be  forgotten.  My  thanks  are  also  due  to  Dr  Choksy  of  Bombay 
and  Dr  Gregory  of  Cape  Town  for  the  photographs  representing  plague 
patients,  also  to  the  Colonial  and  India  Office  for  access  to  official 
records;  to  the  Local  Government  Board  for  Dr  'Choiiison's  translation 
of  the  Paris  Convention,  and  to  the  Controller  of  His  Majesty's 
Government  for  permission  to  reproduce  that  translation. 


W.  J.  SIMPSON. 


King's  College,  London, 
March,  1905. 


CONTENTS. 

PART  I. 
HISTORY   AND   DISTRIBUTION   OF   PLAGUE. 

CHAPTER  I. 

PAGE 

PLAGUE    FROM    THE    EARLY    CENTURIES   TO    THE    19TH    CENTURY  ,        1 

Definition. — The/antiquity  of  iilague. — Plague  in  Syria,  Egypt,  and  Lybia. — 
The  first  recorded  iJandemic-  -Account  of  the  plague  at  Constantinople  by 
Procopius. — Account  of  the  plague  at  Constantinople  in  558  by  Agathias. 
Account  of  the  plague  at  Antioch  by  Evagrius. — Information  scanty  concerning 
other  countries  attacked. — References  to  the  pandemic  by  Gregory,  Bishop  of 
Tours. — Account  of  Paulas  Diaconus. — Plague  in  Ireland. — Plague  from  the 
7th  century  until  the  Crusades. —  General  retrocession  and  quiescence  of  plague 
in  Europe,  Egypt,  and  Syria  for  sevei-al  centuries. — Plague  at  the  time  of  the 
Crusades  and  after. — The  second  recorded  pandemic,  later  called  ;the  Black 
Death. — Constantinople  one  of  the  gateways  by  which  the  pandemic  entered 
Europe. — The  course  of  the  pandemic  as  described  by  an  Arabian  author. — 
Pandemic  distinguished  by  its  rapid  .spread  and  destructiveness.— Guy  de 
Chauliac's  description  of  the  plague  at  Avignon.— Le  Baker  de  Swynebroke's 
account  of  the  epidemic  in  England. — Plague  in  the  15th,  16th,  and  17th 
centuries. — Plague  in  London  in  the  16th  and  17th  centuries. — Recrudescences 
and  epidemic  waves  fi-om  old  endemic  centres. — Remarkable  cessation  of  plague 
in  Western  Europe  at  the  end  of  the  17th  century. — Plague  in  the  18th 
century.— Plague  in  West  Barbary.— Plague  in  the  19th  century.— Disappear- 
ance of  plague  from  Turkey  and  Egypt  in  the  middle  of  the  19th  century.— 
Recrudescence  of  plague  in  Arabia,  Mesopotamia,  Persia,  and  13enghazi.— 
Plague  in  the  province  of  Astrakhan. 

CHAPTER    II. 
PLAGUE   IN    INDIA 40 

Plague  in  India.— Plague  in  the  early  part  of  the  17th  century.— Plague  in 
the  Punjaub.— Plague  in  Ahmedabad.— Plague  in  Agra.— Plague  at  the  end  of 
the  17th  century.  —Plague  in  the  19th  century.— The  districts  of  Garhwal  and 
Kumaon  endemic  centres  of  plague  in  India. 


Contents  xv 


CHAPTER   III. 

PAGE 

THE    PRESRNT    PANDEMIC 48 

The  present  pandemic  originated  in  Yunnan,  une  of  the  Western  Provinces 
of  China. — Topographical  description  of  Yunnan. — Trade  routes  from  Yunnan.— 
Condition  of  Yunnan  in  1871  as  observed  by  M,  Rocher. — M.  Rocher's  account 
of  plague  in  Yunnan. — Ei)ideniic  preceded  by  sickness  and  mortality  among 
rats. — Dr  Lowry  of  Pakhoi  gives  first  medical  account  of  plague  in  Southern 
China  at  Pakhoi. — Plague  first  appeared  at  Pakhoi  in  1867. — Trade  route  from 
Pakhoi  to  Yunnanfu. — Plague  endemic  in  Pakhoi  from  18G7  to  1884. — Plague 
not  extinct  in  adjoining  prefecture  to  that  of  Pakhoi. — Plague  at  Mengtze,  1874'' 
to  1893.  Plague  at  Nanningfu  and  Kwaium  in  1893. — Plague  at  Canton  in 
1894. — Canton  connected  with  the  chief  towns  and  districts  of  Kwangsi  and 
Kwantung.— Plague  in  Canton  in  January,  1894. — Hongkong  the  largest  and 
most  important  European  possession  near  Canton. — Plague  discovered  in 
Hongkong  in  May,  1894. — The  plague  bacillus  discovered  in  Hongkong  by 
Dr  S.  Kitasato  and  later  by  Dr  Yersin. — Plague  in  Macao  in  April,  1895. — 
Canton  and  Hongkong  become  centres  of  distribution  of  plague. — Plague  at 
Bombay  in  1896. — Commencement  characterised  by  mildness  ^nd  slow  exten- 
sion.— Opposition  to  the  adoption  of  preventive  measures. — Progress  of  the 
disease  associated  with  the  migration  of  rats. — Height  of  the  first  Bombay 
epidemic  in  Feb.,  1897. — Extension  of  the  disease  to  the  Bombay  Presidency 
and  to  other  provinces  in  India. — Slow  diffusion  of  the  plague.— Severity  of 
epidemics  at  Dharwar  and  Poona. — Extension  of  the  plague  to  other  Presi- 
dencies.— Gradually  increasing  mortality  from  the  j^lague  in  India. — Extension 
of  the  plague  from  India  and  China  to  other  parts  of  the  world. — Distribution 
of  plague  in  different  parts  of  the  world. — An  endemic  centre  in  Uganda. 


PART   II. 
EPIDEMIOLOGY   OF   PLAGUE. 

CHAPTER   IV. 

NATURE   OF    INFECTION 

Earlier  views  on  the  nature  of  infection. —Discovery  of  the  plague  bacillus 
and  the  evidence  as  to  its  causal  relationship.— "^lorphological  and  staining 
characteristics  of  the  plague  bacillus.— ^Cultural  characteristics.— Involution 
forms.  -  -  Characteristic  growth  in  bouillon.— Formation  of  stalactites.--Kitasato's 
plague  bacillus.— The  vitality  of  the  plague  bacillus.— In  different  media.— Effect 
of  cold.— Effect  of  heat.— Effect  of  sun.— Effect  of  drying.— Variation  in  vii-u- 
lence. — Effect  of  the  plague  bacillus  in  animals. 


xvi  Cottfntfti 


CHAPTKK    V. 

PAOK 

THE    REI.ATIONSJIII'    OF    EPIZOOTICS    TO    I'LAGUE 96 

Rats  and  mice  susceptible  to  natural  plague  infection. — Relationship 
between  certain  e[)izootics  and  epidemics  of  plague  a  current  belief  for  many 
centuries. — Observations  of  epiz(«)tics  associated  with  plague  e2)idemics. — 
Plague-stricken  rats,  their  appearance  and  behaviour. — Cats  affected  with 
])lague. — Other  animals  affected  with  plague.— Result  of  experiments  to 
produce  plague  in  animals. — Experiments  by  German  Connnission. — Experi- 
ments on  animals  by  Austrian  Commission. — Hafi'kiue's  experiments. — Wilm's 
experiments. — Experiments  on  a  large  scale  carried  out  in  Hongkong  in  1902. 
—Plague  in  man  possibly  not  infrequently  caused  by  food  contaminated  with 
plague  infection. — Plague  in  animals  under  conditions  of  natural  infection. 

CHAPTER    VI. 

DIFFERENT  VIEWS  AS   REGARDS   THE    ETIOLOGY    OF    PANDEMICS   AND 

EPIDEMICS   OF    PLAGUE 130 

1_  Some  questions  related  to  spontaneity. — Origin  of  plague  long  attrilnited  to 
putrefaction  of  dead  bodies,  or  to  great  physical  disturbances. — Pariset's  theory. 
— Creighton  supports  Pariset's  \'iews. — Mortality  of  rats  from  plague  not 
against  Pariset's  theory. — Origin  of  plague  attributed  to  great  calamitie.s, 
cosmic  and  telluric. — The  Black  Death  preceded  by  great  disturbances  in 
the  balance  of  natui-e. — Creighton  places  the  origin  of  the  Black  Death  on 
the  borders  of  the  Euxine  or  Black  Sea. — Considerations  showing  the  difficulty 
and  even  the  impossibility  of  now  locating  the  origin  of  the  14tli  century 
pandemic. — Volcanic  eruptions  are  recorded  to  have  rendered  plants  and 
herbage  poisonous. — Great  multiplication  of  disease  germs  associated  with 
lean  or  famine  years. -pExceptional  meteorological  conditions  preceded  the 
epidemic  of  jjlaguc  in  Hongkong. — Scarcity  preceded  plague  in  India. — Ab- 
normal season  preceded  epidemic  of  plague  in  Hongkong. — Unusual  season 
l)receded  epidemic  of  plague  in  Capo  Town. — Conclusion. 

CHAPTER    VJI. 

VARIATION     IN     POWERS     OF     DIFFUSION     OF     EPIDEMICS,     AND     THE 

EFFECT    OF    SEASONAL    INFLUENCES    ON    THEM  ....    143 

Variation  in  diffusive  powers. — Self-limiting  plagues. — The  existing  pan- 
demic po.ssesses  comparatively  small  diffusive  powers. — The  danger  of  existing 
pandemic. — Plague  epidemics  and  seasonal  influences. 

Plague  epidemics  occur  at  i);u-ticular  .seasons  of  the  year. — Temperature  -) 
affects  the  endemicity  of  plague.  -  Season  a  composite  force. — Mr  Baldwin  ^ 
Latham's  analysis  of  the  infiueiu;e  of  climatic  factors  on  plague.-  The  \ai"ying 
condition  of  the  soil  .-ind  its  fluctuating  temperature  likely  to  have  an  effect  on 
microbic  and  insect  life. — The  temperature  of  the  air  itself  not  tlii'ectly  in- 
fluential.— At  the  end  of  the  plague  season  infected  articles  lose  their  infectivity, 
but  may  regain  it  the  following  season. — Instances. — The  same  observation  has 
been  made  in  regard  to  small-pox  and  vaccine. — Seasonal  periodicity  of  2)lague, 
and  seasonal  breeding  period  of  the  rat. 


Conteiits  xvii 


CHAPTER   VIII. 

I'ACiK 

VARIATION    IN    VIRULENCE    OF    PLAGUE    EPIDEMICS  ....    1.59 

^Variation  in  virulence. — Mild  epideuiiu  of  plague  at  Astrakhan  and  A^et-   ' 
lianka. — The  Vetlianka   outbreak   suddenly  acquires  great   virulence. — Early 
malignity  of  the   Avignon   epidemic  of   1348,  with  its  pneumonic  symptoms 
followed  by  a  less  malignant  type. 

Different  types  with  varying  degrees  of  virulence  majf  be  seen  running 
concurrently  or  following  one  another  in  the  same  epidemic. — Four  different 
types  of  plague  in  the  Pali  epidemic  of  1836. — Five  degrees  of  severity  noted 
in  the  Marseilles  epidemic  of  1720.— Three  degrees  of  severity  observed  in  the 
Russian  epidemic  of  1771. — An  Aura  Pestilentiae  noticed  in  the  Egyptian 
epidemic  of  1834-35. — Three  degrees  of  severity  in  the  Egyptian  epidemic  of 
1834-35. — Sporadic  cases  of  mild  plague  may  precede  severe  epidemics  of 
plague,  or  they  may  bridge  over  the  intervals  of  epidemics. — The  import  of 
glandular  swellings  before  and  after  plague  prevalence. — Presence  and  absence 
of  certain  symptoms  in  different  epidemics. — Extraordinary  and  coloured  sweats 
in  the  plague  of  London. — Plague  may  increase  in  virulence  if  it  appears  in  the 
same  locality  in  successive  years. 

Variation  in  the  virulence  of  the  disease  dependent  on  conditions  to  which 
the  microbe  snd  those  attacked  are  exposed. — Natural  immunity. — Plague 
commits  its  greatest  ravages  on  people  subjected  to  depressing  influences. 

White  people  have  a  fairly  uniform  mortality  from  plague  wherever  they 
may  be  attacked. — Susceptible  races  may  become  less  susceptible  out  of  their 
own  country. — Susceptibility  may  vary  in  the  same  race  in  different  localities. 
— Variety  of  type  is  seen  in  all  infectious  diseases. 


CHAPTER    IX. 

FOSTERING    CONDITIONS    OF    ENDEMICITY    AND    EPIDEMICITY  .  .   176 

Discrimination  between  recrudescence  and  endemicity. — Endemic  centres. — 
Kurdistan. — Kumaon  and  Garhwal. — Characteristics  of  the  outbreaks. — 
Poverty  of  the  inhabitants,  exceptionally  insanitary  houses  and  close  as- 
sociation of  animals  and  men. — Dr  Francis'  description  of  the  houses.  —  Dr 
Planch's  description  of  the  houses. — Conditions  in  Yunnan. —Conditions  in 
Assyr. — Fostering  conditions  of  plague  prevalence  similar  in  exotic  localities 
to  those  in  endemic  centres. —  Paris  in  the  17th  century. — Oporto  in  the 
19th  century.- Canton  in  the  19th  and  20th  centuries. — Hongkong  in  the 
19th  and  20th  centuries. — Bombay  in  1896. — The  chawls  of  Bombay. — The 
crowded  buildings  in  Mandvi. — The  Jains  and  their  indifference  to  death. — 
A  scene  in  a  Bombay  building. — Mortality  in  the  Bombay  outbreak  of  1896-97 
small  owing  to  preventive  measures. — The  three  conditions  in  city  of  Bombay 
observed  by  experts. — Notes  of  a  morning's  inspection  in  Bombay. — Cape 
Town. — Plague  chiefly  a  disease  of  the  poor. — A  Chinese  village. — Macao. — 
Conclusion. 


xviii  Contents 

CHAPTEll   X. 

PAGE 

DIFFUSION    AND    MODES   OF   DISSEMINATION 194 

Plague  is  transportal ile,  l)ut  icciuiros  i-crt.iin  carriers  for  its  disjseuiiuatioii.- 
Plague  travels  by  the  most  frequented  ti'ade  routes. — Persons  sick  or  incubating 
plague  carry  the  infection  to  other  localities. — Healthy  persons  sometimes  carry 
the  infection. — Infection  transported  and  disseminated  by  infected  clothes. — 
The  infection  conveyed  to  a  new  centre  may  aftect  rats  before  human  beings. — 
Additional  risk  of  extension  from  an  infected  locality  during  the  height  <jf  an 
epidemic. — The  infection  carried  long  distances  in  ships. — Transport  of  infec- 
tion facilitated  by  the  movements  of  crowds. — Transport  of  infection  may 
be  by  vehicles  other  than  infected  persons  or  infected  clothes. — Instances 
of  infection  being  connected  with  cargoes  and  infected  rats. — Cape  Town. — 
Mossel  Bay. — East  London. — Durban. — Osaka. — Rhajpur. — Pisco. — Callao. — 
Asuncion  — Unsie. — Inland  towns  sometimes  infected  by  conveyance  by 
railway  of  rats  infected  with  plague  or  rat-infected  merchandise. 

CHAPTER   XI. 

MODES   OF    DISSEMINATION    IN    AN    INFECTED    LOCALITY  .  .  .210 

Pneumonic  types  of  plague  infectious. — Septicaemic  plague  infectious. — 
Original  source  of  infection  in  the  house  of  Kaviraj  Dwarka  Nath  in  Calcutta. — - 
Bubonic  plague  not  directly  infectious. — Dissemination  by  infected  clothes. — 
Dissemination  by  infected  rats.  —Special  value  attaches  to  the  observations  in 
South  Africa  and  Australia. — Observations  in  Hongkong. — Observations  in 
India. — The  agency  by  which  jilague  is  transmitted  from  the  rat  to  man. — 
The  flea  theory.- -In  the  16th  and  17th  centuries  cats,  dogs,  pigeons,  and  fowls 
were  believed  to  spread  plague. 

Ancient  belief  in  the  possibility  of  insects  conve^-ing  infection. — Plague 
bacilli  detected  in  ants,  bugs,  and  flies. — The  role  of  animals  other  than  rats 
in  the  dissemination  of  plague  not  judged  to  be  important  from  existing  obser- 
vations.— The  tarbagan  (Arctomys  bobac)  subject  to  an  epizootic  much  like 
plague. —  The  disease  in  man  contracted  from  sick  tarbagans. 

PART   III. 
PLAGUE    IN    THE    INDIVIDUAL. 

CHAPTER   XT  J. 

MORHID    ANATOMY    AND    PATHOLOGY 226 

Skin. — Lymphatic  gland.s. — External  primary  l)uboes. — Veins  in  the  vicinity 
of  the  bubo  affected.-  Internal  buboes. — Secondary  buboes. —Histological 
changes  in  primary  bubo.— Histological  changes  in  .secondary  bulioes.  — The 
plague  bacillus.— Spleen.— Circulatory  system. — Respiratory  system.— Liver. — 
Alimentary  canal. — Urinary  system. — Nervous  system. — Autopsies. — Bacterio- 
logical condition. — Histological  condition. 


Contents  xix 

CHAPTER   XIII. 

I'.VGE 

CHANNELS   OF    INFECTION 24!) 

Infection  through  skin  direct  to  the  lymphatics. — Power  of  the  bacilhis  to 
enter  the  system  through  a  small  lesion  in  the  skin  without  producing  a  local 
reaction  at  site  of  inoculation. — Infection  through  the  skin  direct  to  the 
blood  vessels. — Older  view  is  that  plague  is  a  general  disease,  and  that  buboes 
are  its  local  manifestations. — Infection  through  the  mucous  membrane. — 
Infection  through  the  respiratory  tract. — Mixed  infection. — Mode  of  exit  of 
infection  from  the  body. — The  duration  of  infectivity  of  convalescents. — Incu- 
bation period  of  plague. 

CHAPTER  XIV. 

CLINICAL   FEATURES 260 

Different  classification  or  types  of  plague.  —  Plague  with  and  without  buboes. — 
Incubation  period. — The  benign  bubonic  or  Pestis  minor. — The  grave  bubonic 
or  Pestis  major. — Causes  of  death. — Progress  after  the  6th  or  7th  day. — 
Septicaemic  plague. — Pneumonic  plague. — Characteristic  symptoms. — Symp- 
toms considered  in  relation  to  systems  affected. — Temperature. — Temperature 
charts. — Lymphatic  system  buboes. — Contents  and  condition  of  buboes. — 
Size.  —  Pain.  —  Tenderness.  —  Termination.  —  Situation.  —  Inguinal  buboes. — 
Axillary  buboes. — Cervical  buboes. —Multiple  buboes. — The  skin  petechiae. — 
Gangrenous  pustules  or  carbuncles. — Nervous  phenomena. — Vascular  system. — 
Blood. — Digestive  system. — Urinary  system. — Respiratory  system. — Compli- 
cations and  sequelae. — Eye  diseases.  —  Marasmus  and  chi-onic  plague. — 
Pregnancy.  —  Arthritis.  —  Concurrent  diseases.  —  Second  attacks.  —  Cases  of 
plague. — Ambulant  variety.— Septic  and  fulminating  variety. — An  atypical 
case. — Plague  pneumonia. — Dr  Manser's  illness. — -Dr  Midler's  illness. 

CHAPTER   XV. 
DIAGNOSIS    AND    PROGNOSIS 306 

Diagnosis  generally  not  difficult  in  a  typical  case  of  plague. — Bacteriological 
test. — The  serum  test. — The  absence  of  lymphangitis. — Chief  difficulty  arises 
from  the  Protean  character  of  plague. — Ambulant  plague. — Septic  type. — 
Pneumonic  plague. — Influenza  and  plague. — Tonsillar  plague. — Prognosis. — 
Caution  as  to  prognosis. — Favourable  signs. — Unfavourable  signs. 

CHAPTER   XVI. 

TREATMENT 31(} 

Curative  treatment  powerless  in  the  most  virulent  forms  of  plague. — 
Treatment  of  plague  in  the  past. — Bleeding. — The  evacuant  treatment. — The 
stimulant  and  tonic  treatment.  —  Oil  friction  trcatiyent. — Treatment  of  buboes. — 
Cold  water  treatment. — Suggested  antiseptic  treatment. — Basis  of  the  present 
day  treatment  of  plague. — Attempt  at  specific  treatment.— Observations  on  the 


XX  CoHfeiifs 

PACK 

sora  prepared  by  Yersin,  Roiix,  Calmettc,  and  Borrel. — Amoy. — Bombay. — 
Karad. —  Karachi. — Oporto. —  Glasgow. — Cape  Town. — Natal.  —  Hongkong. — 
Bri.sbane. — Observations  on  Lustig's  serum. — Observations  on  Prof.  Terni's  and 
Bondi's  serum.  -Observations  on  Kitasato's  serum. — Dosage  of  serinn.— Anti- 
septic tre<itment. — Carbolic  acid. — Cyllin. — General  treatment. — Nursing. — 
Hygienic  conditions.—  ]\Icdicines. — Local  treatment  of  buboes. — Treatment 
of  carbuncles. — Treatment  during  convalescence. — Propiiylactic  measures  in 
an  infected  bouse. — Use  of  disinfectants. — Protective  inoculation.  —  Personal 
hygiene. — Hygiene  of  the  house. 


PAET   IV. 

MEASURES   FOR   PREVENTION   AND   SUPPRESSION 
OF   PLAGUE. 

CHAPTER   XVIT. 

MEASURES    EMPLOYED    BEFORE   THE    DISCOVERY    OF   THE    BACILLUS    .  333 

Two  periods  to  be  considered. — Preventive  measures  depend  on  the  views 
which  are  held  concerning  the  cause  of  the  disease. —  Trespass  ofterings. — 
llemoval  from  plague-stricken  locality. — Fumigation  of  the  dwellings  and 
attention  to  diet. — Prayers  and  processions. — Resignation  and  fatalism. — 
Disposal  of  the  dead. — Isolation  of  the  rich. — First  preventive  measures  of  an 
organised  nature  in  Venice  in  1348. — First  governmental  measures  in  1374. — 
Lazaretto  established  by  the  Venetians  in  1403. — A  council  of  health  and 
quarantine  established  in  1485  in  Venice. — The  Venetian  system  of  quarantine. — 
Preventive  mejxsures  against  extension  of  plague  to  other  countries. -f-Measures 
in  Austria  and  Germany  in  16th  century. — Educational  tracts  an^pamphlets 
in  16th  centuryv^Measures  in  London  in  16th  century. — First  government 
orders  issued  in  London  in  Henry  VI IPs  reign. — Orders  more  severe  in  the 
reign  of  Elizabeth. — Severity  of  measures  in  Aberdeen. — Enlightened  policy  in 
Edinburgh. — First  quarantine  station  for  London  established  in  1664. — 
Special  plague  officials  appointed  in  evei-y  parish  in  London. — Regulations  in 
London  against  the  plague  in  the  17th  century. — Hodges  oi)po.sed  to  the  shutting 
up  the  sick  and  the  well  in  the  .same  house. — Dr  Mead's  views  in  1720. — 
Advocacy  of  the  establishment  of  ho.spitals  and  quarantine  stations. — Evacua- 
tion of  infected  houses. — Passport  sy.stem  for  those  wishing  to  leave  infected 
towns. — First  Quarantine  Act  passed  in  reign  of  George  IV. — International 
preventive  measures  introduced  in  1831  and  1838. --Disappearance  of  plague 
from  Turkey  and  Kgypt  attril>uted  to  these  international  measiu-es. — Other 
causes  also  at  work. — Failure  of  measures  to  prevent  spread  of  strong  invading 
epidemics,  and  the  possible  cause. — Intei-national  conferences  of  European 
Powers  to  consider  measures  of  mutual  i»rotection  against  epidemic  disease 
from  the  East. — New  basis  for  maritime  preventive  measures  adopted  at  the 
Vienna  Conference,  1874. — Quarantine  and  sanitary  cordons  brought  into 
requisition  in  the  Russian  outbreak  of  plague  in  1879. 


Contents  xxi 

CHAPTER   XVIII. 

PAGE 

EXISTING      MEASURES      AGAINST      PLAGUE      AFTER      DISCOVERY      OF 

BACILLUS 354 

Measures  to  prevent  importation  of  plague. 
International  measures.  —  Regulations  of  the  Venice  Convention  of  1897. — 
Merchandise  to  be  prohibited  or  disinfected  if  thought  necessary,  but  not 
q\iarantined. — Quarantine  on  land  frontiers  abolished. —  Quarantine  not  abolished 
for  certain  classes  and  pilgrims. — The  measures  agreed  upon  at  the  Venice  Con- 
vention though  useful  did  not  stop  altogether  the  importation  of  plague. — 
Regulations  of  the  Paris  Conference  of  1903. — Local  measures. — Methods  em- 
[)loyed  for  the  destruction  of  rats  on  board  ships. — The  Clayton  process  for 
the  destruction  of  rats  and  disinfection  of  ships. — Strength  and  properties  of 
the  gas. — Precautions  to  be  taken  in  carrying  out  the  fumigation. — Uses  of  the 
Clayton  disinfectf)r  on  board  ship. — Disinfection  of  baggage. — Necessity  to  be 
in  a  state  of  preparedness. — Local  measures  to  be  adopted  in  anticipation  of  an 
outbreak. — Certain  principles  should  underlie  the  erection  of  plague  hospitals. — 
Health  camps. — Arrangements  for  disposal  of  the  dead. — Administrative 
arrangements. — Bacteriological  examination  of  rats. — Destruction  of  rats  in  a 
healthy  locality  as  a  precautionary  measure. — Methods  available  for  the 
destruction  of  rats. — Traps  and  poison. — Fumigation  with  C'layton's  apparatus. — 
The  employment  of  Danysz'  bacillus. — A  careful  watch  on  prevalent  sickness 
required,  especially  in  the  poorer  quarters. 

CHAPTER   XIX. 

MEASURES   TO   (;OMBAT   AN    OUTBREAK    OF    PLAGUE   IN    A    LOCALITY  .  372 

Preliminary  observations  as  to  the  hindrances  to  a  locality  being  declared 
infected  with  plague. — Commercial,  political,  and  social  forces  nearly  always 
range  themselves  against  the  first  announcement  of  plague  in  a  town. — 
Controversies  in  Bombay,  Calcutta,  Cape  Town,  and  San  Francisco. — Reported 
cases  of  suspected  plague  in  Johaimesburg. — Rats. — No  disease  which  creates 
so  much  alarm  as  plague. — Firmness  and  judgment  required  from  the  com- 
mencement.— Measures  necessary  at  the  commencement  not  suitable  when  the 
epidemic  is  beyond  control. — Accurate  diagnosis  essential  and  its  difficulties. — 
Plague  organisation  previously  planned  to  be  mobilised. — Notitication  to  be 
su2)plemeiited  by  visitation  of  houses  and  other  measures. — Liformation  to 
householders. — Bacteriological  examination  of  rats. — Outline  of  a  plague 
organisation. — Duties  of  the  plague  organisation. — The  most  important 
measures  for  the  suppression  of  2)lague.— Segregation. — Evacuation  of  pre- 
mises.— Circumstances  modifying  retention  of  contacts. — Existing  methods 
of  disinfection  cumbersome  and  unsatisfactory. — The  newest  and  best  method 
of  disinfecting  a  house  infected  with  plague  is  fumigating  with  Clayton's 
apparatus. — To  prevent  recrudescences. — Fumigation  has  its  limits. — Employ- 
ment of  chemical  disinfectants. — Burning  and  exposure  to  high  temperatures. 
— Boiling.  —Exposure  to  the  direct  rays  of  sun  for  three  or  foiu-  days.  -Sanita- 
tion.— Destruction  of  rats. — Destruction  of  rats  by  the  employment  of  the  vii'us 
of  Danysz. — Attenuation  and  exaltation  of  virulence  of  virus. — Manner  in  wliirli 
cultures  of  Danys/.'  bacillus  were  ust'd  in  Cape  Town. — Use  of  Danysz'  cultures 


xxii  Contents 

PAGE 

in  the  outbreak  of  plague  at  Odessa.— Other  methods  employed. — Symptoms  in 
rats  suftering  from  the  Danysz'  bacillus  infection. — Post-mortem  appearances. — 
Bacteriological  examination. — General  biological  characters. —  Staining. — Rapid 
diflPerential  tests. — Confirmatory  dittbrential  tests. — Acute  toxic  cases.— 
Destruction   of   rats   in  warehouses,   etc. 

CHAPTER    XX. 
PREVENTIVE    INOCUL.VTION 402 

Haftkine's  plague  prophylactic  based  on  his  cholera  jtrophy lactic  — Prepara- 
tion of  Haffkine's  plague  prophylactic. — Method  of  inoculation. — Effect  of  the 
inoculation. — Results  of  the  inoculations.  Instructions  to  2)ersons  inoculated. — 
The  prophylactic  of  Lustig  and  Galeotti. 

CHAPTER   XXI. 
CONCLUSION 410 

More  precise  information  required  regarding  plague. — The  facts  known  and 
established  regarding  plague. — The  main  lines  on  which  enquiry  is  needed. 


APPENDIX   I. 

Reported  deaths  from  plague  in  India  in  1904,  extracted  from  the  official 
weekly  returns      .         .         .         .         .         .         .         .         .         .         .         .         .414 


APPENDIX   II. 

THE    INTERNATIONAL   SANITARY    CONVENTION    OF    PARIS,    1903  ; 
With  Appendices,  translated  by  Theodore  Thomson,  Esq.,  M.D. 

PART   I.      GENERAL   PROVISIONS. 

CHAP.    I.      PROVISIONS    TO   BE   OBSERVED    BY   THE    COUNTRIES    SIGNING    THE   CON- 
VENTION ON  THE  APPEARANCE  OF  PLAGUE  OR  CHOLERA  IN  THEIR  TERRITORY   416 

Section  T.     Notification  and  subsequent  communications  to  other  countries  .  416 
Section  II.     The  conditions  under  which  a  local  area  may  be  regarded  as 
infected  or  as  having  ceased  to  be  infected 417 

CHAP.    II.      MEASURES    OF    DEFENCE    ON    THE    PART    OF    THE    OTHER    COUNTRIES 

AGAINST   TERRITORIES  THAT   HAVE   BEEN   DECLARED   INFECTED       .  .  .418 

Section  I.     Publication  of  measures  prescribed       .         .         .         .         .         .418 

Section  II.      Merchandise.  —  Disinfection.  —  Importation    and    Transit.  — 

Baggage 419 

Section  III.  Measures  at  Ports  and  Land  Frontiers  .....  420 
Section  I V.     Measures  at  Land  Frontiers. — Travellers. — Railways. — Frontier 

tracts. — River-ways 426 


Contents 


XXlll 


PART   II,      SPECIAL    PROVISIONS   REGARDING   COUNTRIES 

OUTSIDE  EUROPE.  page 

CHAP.  I.      ARRIVALS   BY   SEA 427 

Section  I.  Measures  at  infected  Ports  on  the  Departure  of  Vessels  .  .  427 
Section  II.     Measures  regarding  ordinary  Ships  from  infected  Northern  Ports 

on  their  arrival  at  the  entrance  to  the  Suez  Canal  or  at  Egyptian  Ports      .         .  427 

Section  III.     Pleasures  in  the  Red  Sea            .......  428 

Section  IV.     The  organisation  for  securing  surveillance  and  disinfection  at 

Suez  and  at  Moses'  Wells 431 

Section  V.     The  passage  of  the  Suez  Canal  in  Quarantine      ....  433 

Section  VI.     Measures  in  the  Persian  Gulf    .         .         .         .         .         .         .  435 

Section  VII.     Persian  ( iulf  Sanitary  Stations         ......  436 

CHAP.  II.   ARRIVALS  BY  LAND 437 

Section  I.     General  Provisions        .........  437 

Section  II.     Turkish  Land  Frontiers      ........  437 


PART   III.      SPECIAL    PROVISIONS   REGARDING    PILGRIMAGES. 

CHAP.  I.      GENERAL   PROVISIONS 437 

CHAP.  II.      PILGRIM-SHIPS. — SANITARY   STATIONS 438 

Section  I.     General  conditions  applying  to  Ships 438 

Section  II.     Measures  before  Departure 440 

Section  III.     Measures  during  the  Voyage 441 

Section  IV.     Measures  on  arrival  of  Pilgrims  in  the  Red  Sea         .         .         .  444 

Section  V.     Measures  for  Pilgrims  retm-ning  home 448 

451 


CHAP.  III.      PENALTIES 


PART    IV. 


ADMINISTRATION   AND    CONTROL. 


L  The  Egyptian  Sanitary,  Maritime  and  Quarantine  Board 

II.  The  Constantinople  Superior  Board  of  Health 

III.  The  Tangier  International  Board  of  Health    . 

IV.  Miscellaneous  Provisions          .... 
V^  The  Persian  Gulf 

VI.  International  Health  Office     .... 


452 
453 
455 
455 
456 
456 


PART    V.      YELLOW    FEVER 


457 


PART    VI.      ADHESION    AND    RATIFICATION 


4.- 


)( 


Appendix  I.     Regulations 
Appendix  II. 

Appendix  III.     Resolutions 
Index     .        .        ... 


457 
459 
459 
461 


LIST   OF    ILLUSTRATIONS. 

Map  of  Yunnanfii  and  surrounding  districts 
Plague  mortality  in  India,  number  of  deaths 
Plague  specimens  showing  Imcilli 
Involution  forms  of  the  plague  bacillus 
HaflPkine's  stalactites    ...... 

Chart  showing  the  relation  of  epidemic  and  epizootic  plague 
Chart  showing  human  plague  and  rat  plague 

Charts  of  temperatures  of  experimental  animals. 

Chart  I.  (Pig) 

Chart  II.  (Pig) 

Chart  III.  (Pig) 

Chart  IV.  (Pig) 

Chart  V.  (Pig) 

Chart  VI.  (Calf) 

Chart  VII.  (Monkey)  .... 
Chart  VIII.  (Monkey)  .  .  ■  . 
Chart  IX.  (Monkey)  .... 

Diagram  A.     Plague  mortality  in  Bombay  in  first  epidemic 

Diagram  B.     Duration  of  epidemics  and  months  of  their  greatest  intensity  in 
difterent  localities  ..... 


PAGE 

53 
73 

80 

84 

87 

101 

102 


117 
118 
118 
119 
120 
122 
123 
124 
125 

147 


148 


149 


Diagram  C.     ]\Iortality  from  plague  for  1903  in  Calcutta,  as  compared  with 
average  of  previous  five  years        ....... 

Diagram  D.     Showing  seasons  of  the  year  of  the  greatest  and  least  exhalation 

from  the  ground between  150  &  151 

Temperature  Charts      ....... 

Inguinal  buboes   ........ 

Axillary  liubo        ........ 

Left  axillary  bubo  with  infiltration  into  chest,  shoulder,  an 
Cervical  bubo        ........ 

Cervical  bubo        ........ 

Popliteal  bubo      ........ 

Cervical  bubo  and  necrosis  on  left  arm         ... 
Supra-trochlear  bubo  and  necrosis  on  arm  . 
Right  inguinal  bubo  and  necrosis  or  cai-buncle  on  luiii 
Carbuncle  or  necrosis  ....... 

Temperature  chart  of  Dr  MUller  .... 

Fig.  (1).     Disinfection  l)y  Clayton  system  of  laden  steamer  infected  with  plague  364 

Fig.  (2).     Poitable  Clayton  apparatus  disinfecting  a  house  ....  391 


pp.  269, 

270 

271, 

272 

276 

277 

id  arm 

278 
279 
280 
281 
282 
283 
285 
286 
304 

MAPS. 

Map  of  the  Bombay  Presidency heticeen  70  &  71 

Map  of  Thana  Collectorate  in  Bombay  Presidency       ......     70 

Map  of  Surat  ("ollectorate  in  Bombay  Piesidency 70 

Map  of  Sind  in  Bombay  Presidency 70 

Map  showing  course  and  distribution  of  Plague  in  Southern  China     hetveen  74  &  75 
Ma])  showing  distrilnition  of  Plague  from  1894  to  end  of  1904     .  „         74  &  75 


PABT   I. 

HISTORY  AND   DISTKIBUTION   OF  PLAGUE. 


CHAPTER   I. 


PLAGUE   FROM   THE   EARLY  CENTURIES   TO   THE 
NINETEENTH   CENTURY. 

Plague  in  the  modern  acceptation  of  the  term  is  a  specific  and 
Definition  infectious  disease   affecting   man   and  some  of  the  lower 

animals,  and  possessing  certain  definite  and  well-marked 
symptoms  which  are  always  more  or  less  present  in  every  outbreak. 
These  symptoms  in  man  are  fever,  severe  headache,  giddiness,  congested 
eyes,  extreme  mental  depression,  stammering,  incoordination  of  the 
voluntary  muscles  when  called  on  to  act,  staggering  gait  and  bodily 
weakness,  accompanied  by  painful  swellings,  with  ejffusions  into  the 
surrounding  tissues,  in  the  groin,  armpit,  neck,  or  other  regions  of  the 
lymphatic  glandular  system,  and  with  an  occasional  eruption  on  the  skin 
of  so-called  carbuncles  or  pustules.  They  end  in  death  in  a  large  per- 
centage of  cases  in  the  course  of  three  to  five  days,  or  even  in  a  shorter 
period.  The  swellings  or  buboes  which  are  so  characteristic  of  the 
disease,  and  which  contain  a  special  micro-organism  recognised  by  its 
bipolar  staining,  may  be  absent  in  a  varying  proportion  of  cases.  In 
the  pneumonic  variety  of  plague,  which  primarily  attacks  the  lungs, 
there  are  no  buboes,  or  only  a  late  development  of  them  as  secondary 
manifestations  of  the  disease.  In  the  fulminating  or  septicaemic  plague, 
which  is  another  rapidly  fatal  variety,  there  are  seldom  any  buboes  to 
be  detected.  Plague  may  be  therefore  with  buboes  or  without  buboes. 
This  fact  has  always  rendered  the  diagnosis  of  plague  very  difficult  and 
uncertain  in  the  early  stages  of  an  epidemic,  though  as  the  epidemic 
develops  the  types  without  buboes  may  be  recognised  clinically, 
especially  the  pneumonic  type  with  its  fever,  spitting  of  blood  and  great 

s.  1 


2  History  and  Distribution  of  Plague       [part  i 

prostration.  Even  the  laity  who  have  seen  much  of  plague  are  able  to 
distinguish  this  form  in  its  most  severe  manifestations.  Since  the 
discovery  of  the  plague  bacillus  both  the  pneumonic  and  septicaemic  types 
can  be  as  readily  recognised  as  the  bubonic  by  the  tests  which  bacteriology 
has  recently  placed  in  the  hands  of  the  physician.  The  sputum  of  the 
one  t}^je  and  the  blood  of  the  other  contain  the  plague  bacillus. 

Accompanying  or  })receding  plague  in  man  there  is  usually  an  out- 
break among  the  lower  animals,  particularly  among  rodents  such  as  rats 
and  mice.  In  these  the  same  micro-organism  is  to  be  found  as  in  man 
and  is  the  causal  agent  of  the  disease.  This  causal  agent  is  trans- 
portable from  place  to  place,  carried  by  infected  persons  or  animals  or 
by  articles  soiled  by  the  infection,  and  may  thus  set  up  in  a  fresh  centre 
plague  which  may  manifest  itself  in  a  sporadic  epidemic  or  pandemic 
form  and  may  assume  a  mild  or  virulent  type. 

It  is  not  in  the  above  restricted  sense  of  a  specific  disease  that 
ancient  writers  on  epidemics  and  epizootics  use  the  term  plague.  With 
them  it  implies  something  more  general  and  is  applied  to  any  pestilence 
in  man  or  beast  with  a  high  mortality.  Dysenteries,  famine  fevers,  the 
fevers  of  armies,  typhus  fever,  small-pox,  and  other  ftital  maladies  in 
man  are  included  in  the  older  designation  of  plague  as  well  as  the 
disease  which  is  now  being  dealt  with.  Under  these  circumstances  it 
is  almost  impossible  to  determine  which  of  the  pestilences  that  pre- 
vailed in  the  Assyrian,  Macedonian,  Egyptian,  Roman,  and  Grecian 
empires  were  due  to  true  plague  and  which  were  due  to  those  other 
diseases  which  went  under  the  same  general  designation. 

That  plague  in  the  specific  sense  understood  in  the  present  day  did 
exist,  especially  in  Mesopotamia,  there  can  hardly  be  any  doubt.  Occa- 
sionally it  is  recorded  that  the  Assyrian  kings  were  deterred  from  visiting 
certain  places  because  of  the  prevalence  of  plague.  The  historian  seldom 
describes  the  symptoms  of  any  pestilence  which  he  mentions,  being 
content  with  relating  that  an  epidemic  raged  at  a  certain  time  and 
describing  its  effects  on  the  inhabitants.  To  assume  that  most  of  the 
epidemics  thus  referred  to  were  plague  is  to  give  an  exaggerated  notion 
of  the  prevalence  of  the  disease  in  the  different  centuries,  while  to 
recognise  as  plague  only  those  epidemics  in  which  the  disease  is 
unmistakeable  from  the  description  of  its  symptoms  would  be  to  give 
a  very  inadequate  conception  of  its  prevalence  and  importance. 

A  middle  course  is  probably  the  safest,  with  the  qualification  that 
plague  epidemics  of  a  severe  type  were  not  nearly  so  numerous  as  is 
generally  supposed.    The  long  interval  between  the  appearance  of  plague 


CH.  i]  Antiquity  of  Plague  3 

in  Europe  and  its  present  threatening  aspect,  or  between  its  occurrence 
in  India  in  the  18th  century  and  its  serious  prevalence  now  in  that 
country  during  the  past  eight  years  is  merely  a  repetition  of  its  behaviour 
in  earlier  times.  The  disease  appears  to  come  in  cycles  between  which 
the  intervals  are  of  considerable  duration.  Papon  \  who  has  collected  a 
chronological  list  of  great  pestilences,  gives  41  epidemics  of  plague  as 
occurring  in  the  course  of  1500  years  before  the  Christian  era,  among 
the  empires  and  nations  the  shores  of  whose  countries  bordered  on  the 
Mediterranean  sea;  109  during  the  first  1500  years  of  the  Christian 
era,  and  45  from  the  year  1500  to  1720,  when  plague  ravaged  Marseilles, 
Aix,  and  Toulon. 

Plague  as  stated  manifests  itself  in  the  sporadic,  epidemic,  and 
pandemic  forms,  and  it  is  only  severe  epidemics  or  pandemics  which 
receive  the  attention  of  the  historian.  Even  in  modern  times  severe 
epidemics  in  one  part  of  the  world  escape  attention  in  another  part, 
and  it  is  not  to  be  expected  that  under  the  conditions  of  the  early 
period  of  the  world's  history,  mention  should  be  made  by  the  nations 
bordering  on  the  Mediterranean  of  epidemics  in  remote  and  unexplored 
places.  With  all  the  advantages  of  modern  life,  with  its  rapid  communi- 
cation and  telegraphic  news,  how  little  is  known  or  heard  of  the  plague 
prevailing  in  China  at  the  present  day  or  of  the  plague  in  India  which 
for  some  months  this  year  caused  some  5000  deaths  a  day.  If  India 
were  not  a  dependency  of  Great  Britain  we  should  hear  still  less.  The 
details  are  in  the  archives  of  the  Government  of  India. 

However  uncertain  may  be  the  nature  of  the  majority  of  pestilences 
The  antiquity     ^f  a  bygone  age  it  is  certain  that  plague  is  a  disease  of      ^ 
of  plague.  great    antiquity,  for   occasionally   in   some    of  the   oldest 

records  the  description  is  sufficiently  explicit  to  remove  all  doubt  as  to 
the  disease  being  plague. 

The  Levant  and  the  countries  adjoining  have  been  the  centres  of  ^ 
plague  for  at  least  3000  years,  the  first  notice  of  the  disease  being  in 
Syria.  Plague  is  mentioned  in  the  Bible  as  occurring  centuries  before 
the  Christian  era  in  the  land  of  the  Philistines,  having  broken  out  in 
Canaan^  during  military  operations  against  the  Israelites.  The  in- 
habitants of  the  cities  of  Ashdod,  Gath,  and  Ekron  as  well  as  those  of 
Beth-shemesh  were  attacked  with  "  emerods  "  or  tumours  in  their  secret 
parts,  the  pestilence  causing  a  deadly  destruction.  It  is  related  that  in 
Beth-shemesh  over  50,000  persons  died. 

1  De  la  Peste,  ou  epoque.s  viemorahles  de  ce  Fleau.     Par  J.  P.  Papon. 

2  1  Samuel,  chaps,  v.  and  vi. 

1—2 


4  History  and  Disfributio)i  of  Plague        [part  i 

Even  at  that  distant  date  the  disease  was  observed  to  be  accompanied 
by  an  epizootic  among  mice,  for  it  is  recorded  that  in  order  that  the 
plague  might  be  stayed  the  Philistines  made  ])ropitiatory  offerings  to 
the  Lord  of  Israel,  of  golden  images  of  their  tumours  and  golden  images 
of  their  mice  that  marred  the  land. 

On  another  occasion  the  retreat  trom  Pelusium  of  Sennacherib's 
army  is  attributed  to  a  pestilence  in  which  field  mice  are  stated  to  have 
played  an  important  part,  and  in  commemoration  of  the  event,  according 
to  Herodotus,  a  stone  statue  of  Sethon  stands  in  the  Temple  of  Venus 
with  a  mouse  in  his  hand,  with  the  following  inscription,  "  Whoever  looks 
on  me  let  him  revere  the  gods." 

There  are  earlier  references  in  which  the  Israelites  are  threatened 
with  the  botch  of  Egypt  and  with  emerods,  the  disease  being  apparently 
well  known.  Hippocrates  gives  no  description  of  the  disease.  He 
however  states  that  "all  fev^ers  complicated  with  buboes  are  bad  except 
ephemerals,"  which  may  possibly  be  considered  as  evidence  that  he  was 
acquainted  with  plague. 

With  the  exception  of  the  biblical  record  there  is  no  known  trust- 
piaeue  in  worthy  account  of  the  disease  until  we  come  down  to  the 

Syria,  Egypt,  works  of  Oribasius  in  the  4th  century  A.D.  in  the  reign 
of  the  Emperor  Julian.  In  this  collection  of  ancient 
authors  there  is  a  fragment  on  plague  by  Rufus  of  Ephesus,  who  lived 
in  the  time  of  the  Emperor  Trajan  and  wrote  at  the  beginning  of  the 
2nd  century  B.C.  He  not  only  refers  to  the  plague  of  his  own  time,  but 
also  to  that  described  by  writers  who  lived  at  least  a  century  before 
him.  Rufus  says,  "^The  buboes  that  one  calls  pestilential  are  very 
acute  and  often  cause  death.  It  is  especially  in  Lybia,  Egypt,  and 
Syria  that  they  are  seen  to  occur.  Dionysius  Curtius  the  Humpback 
has  referred  to  these  buboes.  Dioscorides  and  Posidonius  have  refen'ed 
to  them  at  length  in  their  treatise  on  the  plague  which  in  their  time 
raged  in  Lybia,  and  they  have  said  that  it  was  accompanied  by  an  acute 
fever,  intense  pain,  perturbation  of  the  whole  body,  delirium,  eruption 
of  large  buboes  hard  and  without  suppuration,  developing  not  only  in 
the  usual  places  but  also  in  the  popliteal  space  and  elbow,  although  in 
general  such  inflammations  do  not  form  in  these  places."  A  treatise  on 
plague  written  in  the  3rd  or  4th  century  B.C.  indicates  a  fairly  ancient 
history. 

The  identity  of  the  disease  thus  described  with  plague  admits  of  no 
doubt,  while  to  complete  the  picture  Rufus  further  .states  that  "  one  can 
1  (Euvres  de  Oribase,  Bussemaker  et  Daremherg,  livre  xliv.  c.  xvii.  p.  608. 


CH.  i]  Plague  in  the  Sixth  Century  5 

foresee  a  plague  which  approaches  by  paying  attention  to  the  bad  condi- 
tion which  the  seasons  present ;  to  the  manner  of  living  less  profitable 
for  health,  and  to  the  death  of  animals  which  precedes  its  invasion." 

The  evidence  is  sufficient  to  establish  the  fact  that  plague  is  of 
great  antiquity  and  that  it  prevailed  in  Lybia,  Egypt,  and  Syria  at  an 
early  period  of  the  world's  history  when  these  countries  on  the  southern 
and  eastern  shores  of  the  Mediterranean  played  a  leading  part  in  the 
civilisation  of  the  day  and  their  towns  were  important  centres  of 
commerce.  Plague  has  always  been  more  or  less  connected  with  great 
commercial  centres. 

At  intervals  down  to  most  recent  times  Lybia,  Egypt,  and  Syria 
have  been  the  scenes  of  plague  prevalence.  Situated  in  a  unique 
position,  at  one  time  centres  of  powerful  empires  and  always  the 
gateways  between  the  East  and  the  West,  it  was  there  the  commerce 
of  the  world  converged  during  the  ancient  and  middle  ages.  The  marts 
of  the  ancients  and  of  the  middle  ages  centered  here.  It  was  immaterial 
what  nation  wielded  the  sceptre  of  commercial  supremacy,  the  land  and 
sea  routes  by  which  the  produce  from  Asia  and  Africa  was  brought 
remained  the  same.  For  thousands  of  years  the  Arabs  were  the 
principal  carriers  of  merchandise  to  and  from  the  shores  of  the 
Mediterranean.  They  brought  the  rich  produce  of  the  East  on  camels 
and  in  caravans  over  the  old  caravan  routes  to  Tyre  and  Sidon,  to 
Pelusium,  to  Alexandria,  to  Syria,  and  to  Constantinople,  the  great 
marts  of  which  were  the  binding  links  between  the  East  and  the  West. 
It  was  there  that  the  merchants  exchanged  the  produce  of  the  West 
for  the  produce  of  the  East,  and  it  was  there  that  the  commerce  of  the 
cities  of  Africa  and  Europe  met  that  of  the  cities  of  Asia.  In  times  of 
peace  the  highways  were  thronged  with  caravans  and  merchants,  but  in 
times  of  war  they  were  the  roads  traversed  by  invading  armies. 

The  first  well-authenticated  pandemic  of  plague  is  recorded  to  have 
originated   at  Pelusium  in  Egypt  in   the  year  542   B.C. 
recorded  Pelusium  was  in  those  days  a  large  commercial  entrepot 

pandemic.  ^^  which  the  merchandise  from  Aethiopia,  Mesopotamia, 

and  the  East  was  brought  and  there  exchanged  for  the  merchandise  of 
the  West. 

In  a  busy  and  crowded  mart  of  this  kind  where  merchants  from 
every  commercial  nation  of  the  time  were  gathered  together  for  barter, 
conditions  were  favourable  not  only  to  the  formation  of  a  dangerous 
focus  and  to  the  extension  of  the  disease,  but  also  to  the  disease 
attracting  more  attention  than  its  occurrence  in  some  obscure  village  or 


6  Historji  aiifJ  Disfrihirfion  of  Plague        [part  i 

town,  Pelusium  was  fixed  upon  by  the  historian  as  the  starting-point 
of  the  epidemic,  but  plague  was  more  or  less  prevalent  in  Lybia,  Egypt, 
and  Syria  for  centuries,  and  possibly  in  Aethiopia  an  endemic  centre. 
One  author  distinctly  states  that  it  arose  in  Aethiopia. 

Plague  seldom  arises  in  the  town  in  which  it  assumes  such  dimen- 
sions as  to  attract  more  than  local  attention.  The  pandemic  of  the 
present  day  is  generally  traced  back  to  Hongkong  and  Canton,  tAvo 
commercial  cities,  one  of  which  is  generally  supposed  to  be  its  source, 
whereas  it  will  be  seen  later  on  that  the  actual  origin  was  from  the 
Chinese  endemic  centre  of  Yunnan.  As  a  general  rule  the  distributing 
centres  are  mistaken  for  the  source. 

The  disease  was  slow  in  travelling  in  those  days,  as  it  is  in  these.  It 
took  two  years  to  reach  Constantinople  from  Pelusium.  Procopius  of 
Caesarea  in  his  history  of  the  Persian  war  gives  a  vivid  account  of  the 
epidemic  which  attacked  Constantinople.  For  accuracy  and  faithfulness 
in  detail  it  might  without  difficulty  even  after  1400  years  apply  to  some 
of  those  towns  which  have  been  severely  affected  in  the  present  day. 
Transcribed  the  account  is  as  follows : 

"'About  the  same  time  arose  a  pestilence  which  all  but  entirely 

Account  of          destroyed  the  whole  human  race  and,  as  it  happens,  men 

the  plague         Qf  over-confidence  in  their  own  abilitv  referred  its  oris^in 

at  Constan-  ...  " 

tinopie  by  to  things  which  pour  down  secretly  from  the  heavens,  and, 

Procopius.  indeed,  those  who  profess  a  skilfulness  in  these  matters  do 

often  love  with  marvellous  vain  speaking  to  mention  causes  for  them 

absolutely  incomprehensible  by  the  human  mind,  and  to  devise  certain 

strange  arguments  concerning  nature,  knowing  full  well  that  they  are 

saying  no  word  of  truth   but  quite  content  if  they  can  deceive  the 

average  man  by  their  contentions.     But,  of  a  truth,  no  cause  for  this 

pestilence  can  be  given  or  imagined  except  God.     For  it  did  not  make 

its  attack  in  one  quarter  of  the  world  or  against  any  one  race  of  men,  or 

at  any  certain  time  of  the  year,  whence  any  specious  reasons  for  its 

cause    might    be   given.      Spreading    throughout    the    whole    world    it 

attacked  people  of  every  race  however  far  removed  from  one  another, 

sparing   neither   age    nor   sex.     For  whether   they  differed    from   one 

another  in  dwelling-places  or  in  manner  of  living,  or  in  their  pursuits 

or  any  respect  whatsoever,  so  long  as  the  plague  prevailed  the  difference 

availed  them  not.    Some  it  attacked  in  summer,  others  in  winter,  some  at 

one  time,  others  at  another.     Let  the  sophist  discuss  the  matter,  let  the 

^  Procopius,  De  Bello  Persico,  lib.  ii.  cap.  xxii.  et  xxiii. 


CH.  i]  Plague  In  the  Sixth  Century  7 

meteorologist  take  his  view  each  in  his  own  way,  but  I  am  going  to  relate 
where  this  pestilence  began  and  in  what  manner  it  destroyed  mortals. 

"  It  arose  in  Egypt,  with  the  inhabitants  of  Pelusium,  then  dividing, 
it  spread  one  way  through  Alexandria  and  the  rest  of  Egypt,  the  other 
into  Palestine  which  borders  on  Egypt,  and  then  travelled  over  the  world, 
always  advancing  with  a  progress  marked  by  certain  definite  spaces  of 
time.  For  it  seemed  to  advance  by  a  certain  law  and  to  demand 
a  certain  space  of  time  in  every  country,  discharging  its  venom  against 
no  one  on  the  way  casually,  but  spreading  on  this  side  and  on  that  to 
the  uttermost  ends  of  the  world,  as  if  it  feared  lest  incautiously  it  should 
pass  by  any  corner  or  recess  upon  earth.  It  spared  neither  island  nor 
cave  nor  mountain  top  where  men  dwelt.  If  it  passed  over  any  place, 
only  slightly  or  mildly  touching  the  inhabitants,  it  returned  there  after-' 
wards,  leaving  untouched  the  neighbours  against  whom  it  had  spent  its 
rage  before,  and  it  did  not  depart  from  there  before  it  made  up  the  full 
measure  of  the  dead  in  proportion  to  the  amount  of  destruction  which 
it  had  brought  on  its  neighbours.  Always  beginning  at  the  sea  coast 
it  spread  into  the  interior.  In  the  second  year  it  reached  Byzantium 
about  the  middle  of  the  spring,  where,  as  it  happened,  I  was  staying. 
Such  was  its  origin. 

"Many  persons  saw  visions  of  spirits  arrayed  in  human  shapes.  Who- 
soever came  across  these  visions  fancied  that  they  were  struck  in  this 
or  that  part  of  the  body  by  some  man  who  met  them,  and  as  soon  as 
they  had  met  the  spectre  they  were  smitten  with  the  plague.  And  in 
the  beginning  those  whom  ghosts  of  this  sort  met,  tried  to  avert  them 
by  imploring  the  most  holy  names  and  by  unceasing  expiations,  as  long 
as  each  of  them  could.  But  it  was  all  in  vain ;  for  many  died  even  in 
the  temples  into  which  they  had  fled  for  refuge.  Others,  shutting 
themselves  up  within  their  chambers,  would  not  listen  even  to  friends, 
and  although  the  doors  were  broken  in,  pretended  they  could  hear 
nothing,  fearing  evidently  that  they  were  being  called  out  by  one  of 
the  demons.  Some  did  not  catch  the  disease  in  that  way,  but  when 
a  vision  presented  itself  in  the  form  of  a  dream,  suffered  the  same  as 
those  awake  or  seemed  to  hear  a  voice  which  proclaimed  to  them  that 
they  were  enrolled  in  the  ranks  of  the  dead.  Many,  seeing  no  vision, 
either  when  awake  or  asleep,  as  a  warning  of  the  future,  the  disease 
attacked  generally  in  the  following  way.  On  a  sudden  they  became 
feverish,  some  innnediately  on  awakening,  others  while  walking,  others 
while  doing  one  thing,  others  another.  There  was  no  change  in  their 
colour  and  the  b(jdy  did  not  burn  as  if  attacked  by  fever ;  no  inflamma- 


8  History  ami  Distribution  of  FlcKjue        [part  i 

tion  was  apparent,  but  from  morning  until  evening  the  fever  was  so 
mild  that  neither  the  patient  nor  the  physician  who  felt  the  pulse  had 
any  suspicion  of  danger ;  and  none  of  those  who  caught  the  plague 
thought  of  death.  But,  in  some  cases,  on  the  same  day,  in  others  on 
the  next,  in  others  in  a  few  days  after  there  arose  a  bubo,  not  merely 
on  what  is  called  the  groin,  but  under  the  armpit ;  in  some  cases  the 
bubo  appeared  behind  the  ears  and  in  other  parts. 

"  What  I  have  mentioned  happened  in  pretty  much  the  same  way  to 
all  ,who  contracted  the  disease.  As  to  the  ensuing  symptoms,  I  cannot 
say  whether  the  difference  between  them  arose  from  a  difference  of 
constitution  or  from  the  mere  will  of  the  Author  of  the  plague.  Some 
were  stricken  with  a  heavy  lethargy,  others  with  raving  madness,  but 
each  and  all  suffered  what  was  in  keeping  with  these  results.  Those 
who  were  weighed  down  with  lethargy  always  seemed  to  be  asleep, 
forgetful  of  their  usual  avocations.  If  there  was  anyone  present  to 
look  after  them  they  would  take  food  at  times :  those  who  had  no  one 
to  attend  to  them  perished  for  want  of  food.  But  the  delirious,  unable 
to  sleep  and  thinking  everyone  ready  to  murder  them,  were  struck  with 
►  terror  and  shrieking  horribly  tried  to  flee  away.  Those  who  attended 
upon  them,  distracted  by  the  trouble,  suffered  terribly,  so  that  people 
(  pitied  the  nurse  as  much  as  the  patient,  not  because  the  nurses  caught 
the  disease  by  coming  near  the  patient,  for  neither  the  physician  nor 
layman  caught  the  disease  by  touching  the  sick,  for  many  who  attended 
upon  or  buried  others,  contrary  to  general  expectation,  remained 
unharmed  at  their  post,  and  many  without  running  any  risk  were  seized 
and  died  very  soon,  but  because  they  were  so  terribly  fatigued.  For 
they  had  to  put  back  the  sufferers  who  threw  themselves  out  of  bed  and 
rolled  upon  the  floor,  or  had  to  drag  them  back  and  restrain  them  by 
force  when  they  wished  to  throw  themselves  out  of  window,  when  they 
found  water  they  burned  to  throw  themselves  into  it,  not  from  a  desire 
to  drink,  for  men  threw  themselves  into  the  sea,  but  moved  by  their 
delirium.  Nor  was  the  struggle  in  the  matter  of  food  less,  they  would 
not  take  it  if  they  could  help  it. 

"With  some  of  those  who  were  not  suffering  from  lethargy  or  delirium 
the  bubo  disappeared  and  agonies  greater  than  they  could  bear  took 
away  their  life.  Some  one  may  conjecture  that  the  same  thing  happened 
to  all  the  rest,  but  since  they  were  not  conscious  they  felt  but  little  the 
sense  of  pain  which  their  delii'ium  took  away  from  them. 

"  The  physicians  being  in  darkness  as  to  these  attacks  of  plague  and 
thinking  that  the  fountain-head  of  it  was  to  be  found  in  the  buboes 


CH.  i]  Plague  in  the  Sixth  Century  9 

determined  to  examine  the  bodies  of  those  who  died  of  it ;  they  there- 
fore opened  several  of  them  and  found  a  growth  of  foul  carbuncles. 

"  The  malignant  violence  of  the  disease  killed  some  at  once,  others 
after  many  days ;  with  some,  all  over  the  body  black  pustules,  as  large 
as  a  bean  broke  out.  These  could  not  survive  even  for  a  single  day, 
but  in  the  same  hour  as  the  pustules  appeared  they  breathed  their 
last.     Many  dropped  down  dead  from  a  sudden  vomiting  of  blood. 

"This  I  can  truly  and  sincerely  affirm,  that  the  most  celebrated 
physicians  predicted  the  death  of  several  who,  soon  after,  contrary  to 
the  general  opinion,  recovered,  and  on  the  other  hand  predicted  the 
recovery  of  many  who  were  on  the  point  of  death. 

"  So  in  the  matter  of  this  plague,  no  cause  was  reached  by  man's 
reason.  In  every  case  the  result  was  something  out  of  the  usual.  A 
bath  did  one  patient  good;  it  did  another  just  as  much  harm.  Of 
those  who  were  left  destitute  of  all  help  many  died  and  many  escaped 
without  it.  In  a  word  no  one  had  discovered  any  way  by  which  either 
by  precaution  one  might  avoid  the  plague,  or  when  the  plague  had 
once  been  caught  might  avoid  death.  That  one  man  should  fall  sick 
was  unexplainable ;  that  one  should  escape  seemed  a  mere  matter  of 
chance.  If  a  pregnant  woman  caught  the  plague  death  was  sure  and 
certain.  Some  miscarrying,  others  fairly  delivered  perished  forthwith. 
Yet  it  is  said  that  three  women  in  labour  survived,  though  the  children 
perished ;  ox\  the  other  hand,  in  one  case,  the  mother  died  but  the  child 
lived. 

"  Those  with  whom  the  bubo  swelled  and  filled  with  pus  recovered 
from  the  plague  because  the  violence  of  the  carbuncle  had  grown  less 
and  passed  into  pus,  and  experience  teaches  us  that  this  is  a  sign  of 
recovering  health.  Those  with  whom  the  bubo  remained  unchanged 
the  sufferings  mentioned  above  came  upon.  With  some  of  them  the 
thigh  became  completely  dried,  and  so  however  much  the  bubo  swelled 
it  gathered  no  pus.  There  were  some  who  escaped  with  a  defect  in  the 
tongue,  so  that  as  long  as  they  lived  they  stammered  or  stuttered  in 
such  a  way  that  they  could  not  be  understood. 

"  The  plague  lasted  four  months  in  Byzantium ;  it  was  at  its  height 
for  something  like  three.  At  the  beginning  only  a  few  more  persons 
died  than  ordinarily,  but  afterwards  as  the  evil  increased,  the  number 
of  the  dead  reached  5000  a  day  and  subsequently  10,000  and  even  more 
than  that.  In  the  early  days  of  the  plague  a  man  buried  his  own 
people  and  cast  the  corpses  either  stealthily  or  perforce  into  graves 
belonging  to  others ;  but  afterwards  everything  was  in  utter  confusion. 


10  History  and  Blsfributioii  of  Plague       [part  i 

For  slaves  were  left  deprived  of  their  masters,  and  citizens  who  had 
previously  been  in  the  highest  consideration  found  themselves  destitute 
of  the  services  of  their  domestics,  some  of  whom  were  suffering  from  the 
plague,  while  others  had  succumbed  to  it.  Many  houses  were  left 
absolutely  empty ;  and  it  came  to  pass  that  many  people  from  want  of 
relatives  or  servants  lay  unburied  for  several  days. 

"  To  deal  with  this  the  Emperor  as  was  fit  and  proper  charged 
Theodorus  with  the  business  and  supplied  him  with  soldiers  and  money 
from  the  Treasury.  Theodorus  was  in  charge  of  the  '  Emperor's 
answers,'  laying  before  him  the  quests  of  petitioners  and  conveying 
to  them  the  Emperor's  answers.  The  Romans  call  this  officer  in  Latin 
Referendarius.  Those  whose  houses  had  not  been  made  entirely  deso- 
late buried  their  friends  and  relations  themselves.  Theodorus,  paying 
out  the  Emperor's  money  and  adding  sums  of  his  own,  saw  to  the  burial 
of  the  dead  belonging  to  the  needy.  When  all  the  burial-places  which 
were  in  existence  were  filled  with  dead  bodies  they  buried  the  dead 
bodies  wherever  they  could  round  the  city,  and  other  buriers  pressed 
under  the  numbers  of  the  dying,  ascended  the  towers  of  the  Sycean 
walls.  Removing  the  roofs  of  these  towers  they  cast  their  dead  into 
them  indiscriminately  and  packing  them  wherever  they  could,  when 
they  had  filled  all  of  them  almost  full  they  placed  the  roofs  upon  them 
again.  The  awful  stench  from  these  dead  spreading  over  the  city  at 
all  times,  but  especially  when  the  wind  blew  from  the  direction  of  the 
towers,  became  daily  more  harmful  and  distressing  to  the  citizens. 

"  All  rites  connected  with  the  burial  of  the  dead  were  neglected. 
The  corpses  were  not  carried  out  with  the  usual  funeral  procession  or 
funeral  hymn,  it  was  thought  enough  to  carry  the  dead  to  the  sea  shore 
and  cast  them  out  there,  and  these  they  heaped  up  in  piles  upon  barges 
to  be  carried  out  whither  hazard  would  take  them.  At  that  time,  too, 
the  various  factions  into  which  the  people  had  been  divided,  laying 
aside  their  natural  hatred  attended  to  the  funerals  of  their  dead  in 
common  and  even  buried  those  with  whom  they  had  no  communion, 
and  moreover  those  who  had  been  given  over  to  profligacy  and  who 
delighted  in  wickedness  and  unbridled  licentiousness  of  life,  began 
strenuously  to  practise  piety,  not  because  they  had  unlearned  wicked- 
ness and  acquired  self-control  and  had  become  all  of  a  sudden  lovers  of 
virtue  (for  the  evils  which  either  by  nature  or  long-continued  habits 
or  tradition  have  become  ingrained  in  man,  cannot  easily  be  altered 
unless  some  spirit  of  holiness  has  breathed  into  them),  but  because  in 
most  cases  they  were  appalled  by  the  calamities  before  their  eyes  and 


CH.  i]  Plague  in  the  Sixth  Centttry  11 

thinking  that  their  own  death  was  imminent,  they  were  assuredly 
forced  by  extreme  necessity  and  had  to  learn  self-restraint  from  the 
awful  crisis.  In  consequence  of  this,  as  soon  as  ever  they  recovered 
from  the  sickness  and  had  made  up  their  mind  that  they  were  quite 
out  of  danger,  as  though  the  plague  had  departed  far  from  them,  their 
disposition  fell  back  again  into  evil,  and  becoming  much  more  dissolute 
than  of  old,  they  surpassed  themselves  in  wickedness  and  debauchery  of 
every  kind,  so  that  one  might  say  with  truth  that  the  plague,  whether 
by  accident  or  design,  had  held  a  searching  examination  and  spared  the 
basest  of  the  base. 

"At  that  time  it  was  hard  to  find  any  one  at  business  in  Byzantium : 
those  who  were  in  good  health  remained  at  home  and  either  attended 
to  the  sick  or  mourned  their  dead.  Most  people  who  met  in  the 
streets  were  bearing  a  corpse.  All  business  had  ceased :  all  the 
craftsmen  had  deserted  their  crafts  and  the  work  they  had  in  hand. 
The  result  was  a  dreadful  famine,  which  raged  without  limit,  in  a  city 
which  was  accustomed  to  all  good  things  in  profusion.  To  have  even 
bread  or  anything  else  enough  was  difficult,  and  was  thought  to  be  a 
good  thing,  and  so  untimely  death  came  upon  certain  sufferers  owing  to 
lack  of  food.  But  to  be  brief:  it  was  impossible  to  see  any  one  in  a 
purple  cloak  at  Byzantium,  especially  when  the  Emperor  fell  sick,  for  he 
had  a  swollen  bubo ;  but,  in  a  royal  city  supreme  throughout  the  whole 
Roman  Empire,  all  dressed  as  private,  kept  at  home ;  such  are  the 
particulars  of  the  plague  as  it  appeared  in  Byzantium  and  in  other 
parts  of  the  Roman  Empire.  It  attacked  Persia  too  and  all  the 
countries  of  the  East." 

There  has  been  little  or  no  change  in  the  nature  of  the  disease  from 
the  time  of  its  earliest  description.  Perhaps  the  mental  phenomena  or 
the  eruption  of  pustules  or  some  other  symptom  may  be  more  pro- 
minent in  one  epidemic  than  another,  but  the  similarity  of  symptoms 
and  general  behaviour  of  the  disease  are  remarkably  constant.  There 
is  the  same  sudden  onset  and  the  same  appearance  of  the  bubo  on  the 
day  of  attack,  or  the  next  day,  or  a  few  days  later ;  the  drowsiness  in 
some,  the  madness  in  others,  the  desire  to  wander  and  the  difficulty  of 
keeping  some  patients  in  bed  characterise  the  disease  now  as  formerly : 
the  large  size  and  suppuration  of  the  bubo  indicating  a  milder  attack, 
and  the  reverse  a  severe  and  fatal  illness ;  the  deceptive  appearance  of 
the  patient  rendering  prognosis  difficult,  and  the  comparative  immu- 
nity of  physicians  and  attendants  are  observations  which  apply  equally 
well  to  the  disease  of  to-day  as  it  did  then. 


12  Histori)  and  iJlstrihiUlon  of  Plague        [part  i 

Other  writers  besides  Procopius  refer  to  the  pandemic.  From  these 
Account  of  we  learn  it  continued  for  some  52  years,  visiting  different 
the  plague  at  places.  It  reappeared  in  Constantinople  a  second  time  in 
nopiem558  558.  Agathias  describing  its  second  visit  says:  '"In  the 
by  Agathias.  game  year,  i.e.  558  a.d.,  at  the  beginning  of  spring  the 
plague  again  ffll  upon  the  city  and  destroyed  innumerable  multitudes; 
it  had  never  really  ceased  from  the  time  when  in  the  fifth  year  of  the 
reign  of  Justinian  it  had  first  visited  our  world.  Passing  frequently 
between  whiles  from  one  place  to  another,  and  polluting  one  place  after 
another,  and  so  granting,  as  it  were,  a  truce  to  those  left  alone,  it  then 
returned  to  Byzantium,  deceived,  as  I  think,  before  and  having  departed 
from  these  sooner  than  it  should.  Anyhow,  many  persons  fell  down 
dead  as  though  struck  by  a  violent  apoplexy :  but  those  who  held  out 
the  best  died  at  last  on  the  fifth  day.  The  symptoms  in  this  plague 
were  pretty  much  the  same  as  those  in  the  former.  For  they  had  buboes 
and  fevers,  fevers  continuous  and  not  quotidian  or  daily  fevers  merely, 
and  never  ceasing  in  the  slightest  degree,  but  stopping  only  on  the 
death  of  the  person  whom  they  had  attacked.  Some  people  without 
any  feverishness  or  any  pain,  going  about  their  daily  work,  sometimes 
at  home  and  sometimes  abroad  fell  down,  and  at  once  became  lifeless, 
as  if  they  had  taken  death  as  a  chance  turn  up.  People  of  all  ages 
perished  indiscriminately,  but  especially  the  young  and  vigorous  and  in 
the  flower  of  youth ;  and  of  them  the  males,  for  the  females  were  not 
affected  so  much." 

Evagrius,  a  citizen  of  Antioch,  writing  of  the  starting-point  of  this 
pandemic  states  that  it  began  in  Aethiopia.  He  himself  was  attacked 
when  a  child  at  school.  His  account  supplements  that  of  Procopius, 
being  of  later  date,  although  it  is  evident  ft-om  the  context  that  he 
was  not  acquainted  with  the  writings  of  Procopius  on  the  subject. 

Evagrius  says  :  "  -Now  I  am  about  to  declare  a  certain  historic  which 

was  not  found  until  this  day,  it  is  of  a  certain  pestilent 

the  plague         disease  which  plagued  mankind  the  space  of  two  and  fiftie 

at  Antioch         years  and  prevailed  so  much  that  it  destroyed  in  maner 

by  Evagnus.        j  i.  ./  _ 

the  whole  world.     For  it  is  reported  that  this  contagious 

disease  lighted  upon  Antioch  two  years  after  the  Persians  had  taken  the 

^  Corpus  Scriptoritm  Hi-storiae  Bijzdiitiitae  Niebtihrii.  Atjathiae  Scholastici  Ilisioriarum 
lib.  V.  cap.  X. 

-  The  ancient  ecclesiastical  histories  of  the  first  six  hunehed  years  after  Christ  written 
in  the  Greek  tongue  by  three  learned  historiographers,  Eusebius,  Socrates,  and  Evagrius. 
The  ecclesidntical  Jiistorit'  of  Evanrhis  Schaldxticu.t,  lib.  iv.  cap.  xxviii,  translated  out  of 
the  Greek  tongue  by  Meredith  Harmer,  D.D. 


CH.  i]  Plague  in  the  Sixth  Centiiry  13 

citie  in  some  part  much  like  that  which  Thucydides  hath  described,  in 
other  respects  farre  unlike :  it  began  in  Aethiopia  even  as  that  which 
Thucydides  wrote  of  and  spred  itself  afterwards  throughout  the  whole 
world,  neither  was  there  almost  any  one  that  escaped  the  infection 
thereof.  It  raged  so  vehemently  in  some  cities  that  all  the  inhabitants 
thereof  were  despatched :  with  other  towns  it  dealt  most  gently  and 
mildly.  Neither  began  it  at  any  certain  time  of  the  yeare,  neither  did 
it  cease  and  relent  after  one  maner  and  order,  for  in  some  places  it 
entred  with  winter,  in  some  other  places  about  the  end  of  spring,  in 
certain  countries  about  the  midst  of  somer,  in  certain  others  in  autumne. 
In  some  regions  when  it  had  infected  some  part  of  one  city  or  other  it 
left  the  rest  untouched.  Then  might  a  man  have  seen  very  oft  where 
this  malady  reigned  certain  families  wholly  despatched,  at  another  time 
one  or  two  rooted  out  and  all  the  city  besides  not  once  visited. 
Moreover  (as  we  have  marked  diligently)  the  families  which  escaped 
this  yeare  were  alone  and  none  others  despatched  the  next  yeare,  and 
that  which  is  most  of  all  to  be  marvelled  at,  if  any  which  inhabited  the 
infected  cities  fled  into  other  countries  where  the  sickness  was  not,  they 
onely  Avere  visited,  although  they  removed  (hoping  that  way  to  save 
their  lives)  out  of  ye  contagion  into  ye  cleare.  This  Calamitie  during  the 
terme  and  compass  of  these  years  which  they  call  revolutions  passed 
through  both  towns  and  country,  but  the  greatest  mortality  of  all  fell 
upon  mankind  the  second  yeare  of  the  revolution  which  comprise  the 
term  of  15  yeares :  so  that  I  myself  which  write  this  history  (for  it  will 
not  be  amiss  to  interlace  this,  that  the  consequents  may  agree  with  the 
premises)  while  as  yet  I  frequented  the  schooles,  was  then  troubled  with 
an  impostume  or  swelling  about  the  privy  members  or  secret  parts 
of  the  body,  and  despatched  diversely  and  sundry  kinds  of  wayes  it  fell 
out  to  my  grief  and  sorrow  that  God  took  from  me  many  of  my  children, 
my  wife  also  with  divers  of  my  kinsfolks,  whereof  some  dwelled  in  the 
citie  and  some  in  the  country.  Sych  were  my  adventures  and  such 
were  my  calamities  which  the  course  of  those  lamentable  times 
distributed  unto  me.  When  I  wrote  this  I  was  58  yeares  old.  Not 
two  yeares  before,  this  sickness  had  been  four  times  in  Antioch  and 
when  as  at  length  the  fourth  revolution  or  compasse  was  paste  besides  my 
aforesaid  children  God  took  away  from  me  a  daughter  and  a  nephew  of 
mine.  This  disease  was  compound  and  mixt  with  many  other  maladies. 
It  took  some  men  first  in  the  head,  made  their  eyes  as  red  as  blood  and 
puffed  up  their  cheeks:  afterwards  it  fell  at  their  throte,  and  whomsoever 
it  took,  it  despatched  him  out  of  the  way.     It  began  with  some  with 


14  History  and  Distribution  of  Plague        [part  i 

a  fire  and  voiding  of  all  that  was  within  them,  in  some  others  with 
swellings  about  the  secret  parts  of  the  body,  and  thereof  arose  burning 
fires  so  that  they  died  thereof  within  two  or  three  days  of  the  furthest 
in  such  sort  and  of  so  perfect  a  remembrance  as  if  they  had  not  been 
sick  at  all,  others  died  mad,  and  carbuncles  that  arose  out  of  the  flesh 
killed  many.  It  fell  out  oftentimes  that  they  which  had  this  disease 
and  escaped  the  first  and  the  second  time  died  thereof  afterwards. 
The  order  and  maner  that  men  came  by  this  disease  was  so  diverse, 
that  it  cannot  with  pen  be  expressed.  Some  had  it  by  keeping  company 
and  lying  together :  some  others  onely  by  touching  and  frequenting  the 
infected  houses :  some  again  took  it  in  the  market.  Many  of  them 
which  fled  out  of  the  contagious  cities,  and  were  not  visited  themselves 
infected  where  they  came.  Others  which  kept  company  with  the  sick 
and  touched  not  onely  the  sicke  but  the  dead  also  were  not  at  all. 
Other  some  who  gladly  would  have  died  for  the  sorrow  they  conceived 
because  their  children  and  deare  friends  were  departed,  and  therefore 
thrust  themselves  among  the  sick  could  not  have  their  will,  the  sickness 
did  as  it  were  fly  away  from  them.  This  pestilent  disease,  as  I  said 
before,  reigned  throughout  the  whole  world  the  space  of  two  and  fiftie 
yeares  and  exceeded  all  the  diseases  that  ever  had  been  before 
Philostratus  wondered  at  the  plague  which  was  in  his  time  because 
it  continued  fifteen  yeares.  But  the  things  that  are  to  come  are 
uncertain  and  unknown  unto  men  and  they  tend  to  the  end  which  God 
hath  appointed,  who  knoweth  both  their  causes  and  what  shall  become 
of  them."  It  will  be  noticed  that  Evagrius  refers  to  a  diphtheritic  or 
tonsillar  form  of  plague,  to  a  bubonic  form,  and  to  a  carbuncular. 

The  information  as  far  as  it  goes  concerning  this  pandemic  is  very 

definite.  Procopius,  Agathias,  and  Evagrius  agree  in  the 
scant^co^n-^  disease  being  not  only  very  destructive  but  also  very  wide 
cemuig-  other  spread.  Probably  the  remarks  as  to  its  passing  over  the 
attacked.  whole  world  apply  less  to  Europe  than  to  Asia  and  Africa, 

with  which  authors  were  better  acquainted.  But  beyond 
the  outbreak  they  describe  there  is  hardly  any  information  as  to  other 
localities  attacked ;  nor  is  it  to  be  found  in  other  authors.  As  regards 
Europe  this  silence  may  be  explained  by  the  conditions  of  aftairs  at  this 
time.  Rome  had  fallen.  The  dissolution  which  had  overtaken  the 
western  portion  of  the  Roman  empire,  overwhelming  it  with  chaos,  ruin, 
and  destruction,  was  followed  by  an  age  in  whioh  culture  and  leisure 
were  almost  unknown.  Ignorance  and  strife  were  not  favourable  to 
literature,  nor  to  the  record  of  historical  events.     Whatever  was  accom- 


CH.  i]  Plague  in  the  Sixth  Centunj  15 

plished   in    this    direction   was  done    by  some  of  the   clergy  in   their 

ecclesiastical  chronicles.     There,  mixed  up  with  accounts  of  religious 

ceremonies   and    of   the    doings    of    kings,    nobles,    and    bishops,    may 

occasionally  be   found  allusions  to  the   pandemic.     They  are   however 

mere  echoes  and  traces  of  the  disease  infrequent  in  their  occurrence, 

which  while  affording  evidence  as  to  its  virulence  leave  us  none  the 

wiser  as  to  its  course  or  extent  in  the  countries  attacked. 

In  his  ecclesiastical  history  of  the  Franks  and  in  his  other  works 

Gregory,  Bishop   of  Tours,   mentions   several   times   the 

Keferences  to      ravages  of  plague. 

the  pandemic  °  i      o  .        .     „   ,  „ 

by  Gregory,  (a)     In  546  the  "Lues  ingumaria    devastates  Germany. 

xiS^s^^^  (^)     In   552   it  rages   in  different  countries,  and  de- 

populates particularly  the  province  of  Aries. 

(c)  In  563  it  is  in  Auvergne,  after  an  inundation,  and  attacks 
Clermont,  where  the  mortality  was  so  great  that  it  was  impossible  to  count 
those  that  died.  Coffins  and  biers  failed,  and  ten  and  even  more  than 
ten  persons  were  buried  in  the  same  trench.  On  a  particular  Sunday 
300  corpses  were  counted  in  the  basilica  of  St  Peter.  Death  was 
sudden.  There  arose  in  the  groin  and  armpit  a  swelling  resembling 
a  serpent,  and  the  poison  so  promptly  affected  the  sick  that  they  died 
in  the  course  of  two  or  three  days.  After  Clermont,  Lyons,  Bourges, 
Chalons,  and  Dijon  were  cruelly  ravaged  by  the  plague.  Instances 
of  heroism  and  of  abject  fear  are  not  wanting  in  the  narrative.  While 
many  fled  for  fear  of  the  plague,  Cato  the  priest  remained  burying  the 
dead,  saying  mass  for  each  victim,  and  died  of  plague  performing  these 
rites.  In  contrast  to  this  Cautin  the  bishop  removed  from  place  to  place 
to  avoid  the  plague,  and  returning  when  it  was  thought  to  be  safe,  was 
nevertheless  attacked  and  died. 

(d)  In  582  the  disease  is  in  Narbonne  and  evidently  of  a  most 
virulent  type:  "Audivimus  enim  eo  anno  in  Narbonensem  urbem 
inguinarium  morbum  graviter  desaevire  ita  ut  nullum  esset  spatium 
cum  homo  correptus  fuisset  ab  eo." 

(e)  In  584  its  ravages  in  the  town  of  Albi  are  such  that  the 
majority  of  the  inhabitants  died,  and  only  a  small  number  of  citizens 
were  left. 

(/)  In  588  it  attacks  Marseilles  and  spreads  from  thence  north- 
wards.     It   is    this    year    im])ortcd  from    Spain    by    a   ship    bringing 

(a)     Ex  libro  de  Gloria  Oonfessorum,  cap.  Ixxix. 

(6)  Recueil  des  Historiem  des  Gaules  et  de  la  France.  Martin  Bouquet.  Tom  ii.  1739. 
Sancti  Georyii  Florentii  Gregorii  Episcopi  Turonenxis  HUtoriae  Ecclcxiasticae  Francorum, 
lib.  IV.  cap.  V.  (c)     Ihid.  lib.  iv.  cap.  xxxi.  (d)    Ibid.  lib.  vi.  cap.  xiv. 

(e)     Ibid.  lib.  vii.  cap.  i.  (/)     Ibid.  lib.  ix.  cap.  xxi.  et  xxii. 


16  History  and  Distribution  of  Plague        [part  i 

merchandise  to  Marseilles  some  of  the  purchasers  of  which  appear  to 
have  been  attacked,  one  fiimily  of  eight  being  destroyed.  It  is  noted 
that  the  disease  was  not  communicated  at  once  to  the  different  houses 
but  remained  some  time  inactive  and  then  suddenly  broke  out.  It  is 
further  remarked  that  afterwards  Marseilles  suffered  epidemically  several 
times  from  the  same  plague. 

{g)  In  590  it  is  in  Rome  following  close  upon  an  inundation  of 
that  city  from  the  Tiber. 

(k)  In  591  it  invades  the  province  of  Marseilles  and  while  a  famine 
desolates  the  towns  of  Angers,  of  Nantes,  and  of  Mans  "Vivariensem 
Avennicamque  urbem  graviter  lues  inguinaria  devastavit." 

There  is  an  account  by  Paulus  Diaconus  of  plague  in  the  province 

of  Lififuria  in  565  in  the  time  of  Narses  :  "^  At  these  times, 
Account  by  o  , 

Paulus  especially  in  the  province  of  Liguria.  a  very  great  plague 

laconus.  broke  out.     For  on  a  sudden  there  appeared  about  houses 

and  dooi-s  and  furniture  and  clothes  .certain  marks,  which,  the  more  one 
wished  to  wipe  them  out,  the  more  and  more  appeared.  But  after  the 
end  of  a  year  there  began  to  grow  on  the  groin  and  other  of  the  more 
tender  parts  small  glands  in  the  shape  of  a  walnut  or  a  date ;  these 
were  soon  followed  by  the  heat  of  a  fever  so  intolerable  that  the  sufferer 
died  within  three  days.  If  anyone  got  over  the  period  of  three  days 
there  was  some  hope  for  him.  There  was  mourning  ever}'where,  every- 
where tears.  For,  as  the  common  rumour  declared  that  the  plague 
might  be  escaped  by  flight,  houses  were  left  deserted  by  their  in- 
habitants, the  dogs  alone  guarding  them  :  the  cattle  were  left  alone  in 
the  fields,  no  shepherd  watching  them.  You  might  see  one  day  towns 
or  camps  filled  with  crowds  of  men,  and  on  the  next  day,  as  all  took  to 
flight,  everything  in  dead  silence.  Children  fled,  leaving  their  parents' 
corpses  unburied.  Parents  forgetting  the  bowels  of  compassion  left 
their  children  suffering  from  the  fever.  If  by  chance  any  of  the  old 
feelings  of  affection  moved  a  man  to  bury  a  relation,  he  himself  was  left 
with  no  one  to  bury  him  and  perished  in  doing  his  duty,  and  while  he 
performed  the  funeral  rites  for  the  corpse  his  own  corpse  was  left 
without  any  burial  rites.  You  might  see  the  time  reduced  to  the 
silence  of  old.  No  voice  in  the  country,  no  whistling  of  the  shepherds,  . 
no  attacks  of  wild  beasts  upon  the  fiocks.  The  cornfields  passing  the 
time  of  reaping  untouched  were  awaiting  for  the  reaper.  The  vine  had 
lost  its  leaves,  its  grapes  were  bright,  but  it  remained  unspoiled.     As 

(g)  hoc.  eit.  lib.  x.  cap.  i.  (h)  Ibid.  lib.  x.  cap.  xxiii. 

'  Rerum  Italicarum  Scriptores,  Muratorii  torn.  i.  1723. 
De  Gesti*  Langohardorum  Pauli  Diaconi,  lib.  ii.  cap.  iv. 


CH.  i]    Plague  in  the  Seventh  and  Eighth  Centuries      17 

winter  drew  nigh,  in  the  hours  of  night  as  well  as  of  the  day,  the 
trumpet  of  warring  hosts  was  heard  and  the  roar  of  armies  resounded 
in  the  ears  of  many.  There  were  no  signs  of  the  footsteps  of  passers 
by,  no  executioner  was  to  be  seen  and  yet  the  bodies  of  the  dead  were 
more  than  the  eyes  could  bear.  Country  districts  had  been  turned  into 
sepulchres  and  the  dwelling-places  of  men  had  become  a  place  of  refuge 
for  wild  beasts.  These  evils  within  the  borders  of  Italy  alone  fell  only 
upon  the  Romans  as  far  as  the  territories  of  the  Boii  and  the  Alamanni." 

A  period  of  52  years  brings  us  to  the  end  of  the  6th  century.  The 
Plague  in  Buide  Connaile,  which  proved  so  fatal  in  Ireland  from  543 

Ireland.  ^^  g^g^  jg  ascribed  by  some  to  plague.    Ireland  was  at  that 

time  in  constant  communication  with  Italy,  and  it  is  supposed  that  the 
infection  was  imported  by  some  of  the  ecclesiastics  who  visited  Rome. 
Certainly  it  is  about  the  middle  of  the  6th  century  the  Irish  Chronicles 
record  that  Tara,  which  till  that  time  was  the  residence  of  the  chief 
king,  was  abandoned.  Diarmait  MacCearbhaill,  the  king,  left  it  and 
never  returned,  and  it  was  never  inhabited  again.  The  royal  burgh 
appears  to  have  been  abandoned  because  nearly  everyone  had  died 
there,  and  the  place  came  to  be  regarded  with  such  dread  that  even  its 
fine  position,  far-extending  view,  and  rich  pastures  could  not  induce 
future  kings  to  return  to  it.  A  hundred  years  later,  in  663,  plague 
again  ravaged  Ireland,  and  in  664  was  epidemic  in  England.  Dr  Norman 
Moore ^  favours  the  view  that  the  plague  in  664  was  brought  to  England 
from  Ireland  and  not  from  the  Continent.  It  is  a  moot  point  whether 
St  Etheldreda  died  of  tuberculosis  or  of  plague.  She  had  a  swelling  in 
her  neck,  which  was  opened  by  her  physician^  three  days  before  her 
death.  In  favour  of  plague  there  is  the  fact  that  pestilence  prevailed 
at  the  time. 

No  more  is  heard  of  plague  in  Europe  till  at  least  a  century  later, 

but  if  we  return  to  the  lands  in  which  it  prevailed  inter- 

tiie  vth  cen-        mittently    if    not    continuously    for    centuries    there    are 

tury  until  the     sufficient  records  to  show  that  although  it  appears  to  have 
Crusades.  .  .  .  .  ...,,, 

died  out  in  Europe  it  continued  to  exist  m  its  old  haunts. 

The  most  valuable  document  in  this  connection  is  "  Kremer's^  great 

epidemics  from  Arabian  sources,"  which  shows  Syria  and  the  Euphrates 

valley  to  have  been  during  the  Saracenic  period  the  scenes  of  repeated 

plague. 

1  A  Lecture  on  the  History  of  Medicine  as  iUustrated  in  English  Literature,  by  Norman 
Moore,  M.D.  •^  Bede's  Eccles.  Hist.  lib.  iv.  cap.  xix. 

*  Ueber  die  yrossen  Senchen  des  Orients,  nach  arabischen  Quellen,  A.  v.  Kreiner,  1880. 

s.  2 


18  Historji  and  Distrihtition  of  Plague        [part  i 

Plague  epidemics  broke  out  at  Ctesiphon  in  628  during  the  reign 
of  Shyrujih,  one  of  the  Persian  kings  of  the  Sassanidae  dynasty.  It 
extended  to  the  Mahonimedan  dominions,  the  foundations  of  which  were 
then  being  rapidly  laid  by  ^lahomet.  This  was  the  first  outbreak  of 
plague  in  Islamic  history.  The  next  was  in  638.  It  broke  out  in 
Palestine  at  the  village  of  Emmaus,  in  Galilee,  and  spread  over  the 
whole  of  Syria.  In  the  same  year  it  appeared  in  Bassora,  carried  there 
by  a  portion  of  the  Arabian  army,  which  had  lost  from  it  in  Syria 
25,000  men.  Among  other  historical  persons  who  died  in  this  epidemic 
was  Abu  Obaidah  Ibn  Garrah.  Two  commanders-in-chief  died  of  the 
disease,  the  third  resolved  to  adopt  preventive  measures  and  distributed 
his  troops  in  the  highlands  and  desert,  whereupon  the  plague  was 
extinguished. 

Besides  many  local  outbreaks  there  were  during  the  7th  century 
three  great  epidemics  in  Syria  and  four  in  Irak.  The  disorganised 
condition  of  these  countries  brought  about  by  the  w^ars  of  conquests 
and  the  conflicts  between  the  Byzantians  and  Arabs  rendered  them 
highly  susceptible  to  the  devastations  of  plague.  Only  twice  in  this 
century  does  the  plague  pass  beyond  its  endemic  centres.  Once  in  686 
it  spreads  into  Egypt  and  there  becomes  epidemic,  and  again  in  697  it 
attacks  Constantinople.  In  the  8th  century  it  was  epidemic  in  Eg3q)t 
in  704,  and  for  the  first  half  of  the  century  in  Syria  about  every 
ten  years.  So  regular  was  its  annual  recurrences  at  Damascus  during 
the  reign  of  the  Caliphs  of  the  Ommiades  dynasty  that  it  became  a 
custom  for  them  to  withdraw  to  the  desert  at  the  season  when  plague 
began  to  appear.  Irak  also  suffered  from  at  least  six  severe  epidemics 
during  the  first  75  years,  Bagdad  being  attacked  with  plague  in  763,  the 
year  after  it  was  built.  There  was  a  wide-spread  epidemic  both  in 
Irak  and  Syria  in  745,  and  it  is  likely  that  the  destructive  plague  w-hich 
prevailed  in  Sicily  and  Calabria  in  746 — 748  and  spread  to  Constan- 
tinople in  749  was  an  incursion  into  Europe  from  the  endemic  centre. 
According  to  Nicephorus  Byzantinus  this  plague  continued  in  Constan- 
tinople for  a  year  and  nearly  exterminated  the  population. 

Paulus  Diaconus  describing  this  epidemic  in  Constantinople  says  : 
"'In  the  same  year  the  plague  beginning  in  Sicily  and  Calabria,  like 
some  devouring  fire,  came  to  Hellas  and  the  Aegean  Islands,  through 
the  whole  fourteenth  indiction,  scourging  the  impious  Constantine,  and 
restraining  him  from  the  madness  which  he  aroused  against  the  holy 
churches  and  their  holy  and  venerable  images.  He,  however,  as 
'  Rerum  ItaUcarum  Scriptores,  Muratorii  torn.  i.  lib.  xxii. 


CH.  i]       Renewed  Activity  in  the  Eleventh  Century        19 

Pharaoh  of  old,  remained  uncorrected.  But  this  plague  of  the  bubo, 
spreading  in  all  directions,  in  the  fifteenth  indiction^  reached  the  royal 
city.  Moreover  in  the  spring-time  of  the  first  indiction  the  plague 
spread,  and  in  the  summer  it  raged  so  furiously  that  even  houses  that 
were  not  attacked  were  closed  and  no  one  remained  except  such  as  were 
bound  to  bury  the  dead. 

"And  so  of  necessity  many  plans  were  devised  :  boards  were  laid  upon 
animals  and  thus  the  dead  placed  thereon  were  taken  to  burial.  Simi- 
larly others  were  piled  in  waggons  and  carried  out.  But  when  all  the 
cemeteries  not  only  in  the  city  but  in  the  suburbs  were  full,  all  the 
reservoirs  without  water,  and  the  pools  and  the  vineyards,  and  the 
private  gardens  inside  the  old  fortifications  were  dug  up  to  ensure  the 
burial  of  the  dead ;  and  despite  all  this  there  was  scarcely  room  to  bury 
the  dead." 

With  the  accession  of  the  Abbasides  and  the  transference  of  the 
capital  of  the  Caliphs  to  Bagdad  and  the  prosperity  which  it  brought 
to  the  country  under  their  sway,  plague  appears  to  have  become 
quiescent  for  some  50  years  in  Bagdad.  Political  capital  was  made  of 
the  cessation  of  plague  with  the  commencement  of  the  Abbasidic 
dynasty.  An  Abbasidic  statesman  in  a  public  speech  in  Damascus  said 
it  was  to  be  regarded  as  a  particular  sign  of  the  mercy  of  God  that 
plague  ceased  when  that  dynasty  began.  But  one  of  those  present,  a 
faithful  adherent  of  the  fallen  dynasty,  answered :  "  God  is  too  merciful 
to  afflict  a  nation  simultaneously  with  two  such  scourges  as  the  plague 
and  the  Abbasides." 

This  quiescence  in  the  valley  of  the  Euphrates  for  some  50  years 

seems  to  have  formed  a  part  of  a  general  retrocession  and 
General  retro-  .  .  ... 

cession  and         decline  of  the  disease  after  its  intermittent  activity  for 

Ta^uTin^  °^      '^^  years  in  Europe,  Asia,  and  Africa.     Subsequent  to  this 

Europe,  pandemic  there  were  only  three  devastating  epidemics  in 

Syria  for  ^^^JP^'  ^^^  i^^  ^^2,  another  in  (386  and  a  third  in  719,  after 

several  which  Eyfvpt  remained  free  of  plague  until  1010,  nearly  300 

centuries.  ^-^  ^  .  ,      ,      ^      °      .  „    ,         .   .        .  „ 

years.    Europe  also,  with  the  exception  oi  the  visitation  oi 

Constantinople  in  697  and  that  of  Sicily,  Calabria,  and  Constantinople  in 

749,  remained  free  from  plague  for  at  least  400  years,  and  Syria  for  200 

years.     While  appearing  in  epidemic  form  at  long  intervals  during  the 

9th  and  10th  centuries  in  Irak  and  Persia  it  was  not  until  the  11th 

^  Indiction.  Tlie  fiscal  period  of  15  years  instituted  by  Coustantine  in  313  and 
reckoned  from  the  1st  of  September  312,  which  became  the  usual  means  of  dating  ordinary 
events  and  continued  as  such  down  through  the  Middle  Ages. 

2—2 


\ 


20  HiHtorif  (dhJ  Distrihiition  of  Plague       [part  i 

centur}-  that  the  disease  began  to  show  a  renewed  activity  and  spread 
into  Syria,  Egypt,  and  Europe.  The  recrudescence  was  coincident  with 
a  decline  in  the  empire  of  the  Caliphs  and  a  rise  in  the  power  of  the 
Turks.  The  struggle  of  the  contending  powers  seems  to  have  produced 
conditions  favourable  to  the  virulence  of  the  plague  in  its  endemic 
centres,  while  the  movements  of  the  different  armies  were  favourable  to 
its  extension  in  those  countries  brought  into  contact  with  them. 

The  conquests  of  the  Sultans  of  Ghazna  are  distinguished  by  a  great 
plague  in  India  in  1032,  which  spread  over  Persia,  Mesopotamia,  Asia 
Minor  to  the  neighbourhood  of  Constantinople,  and  it  is  probable  that 
it  is  this  same  epidemic  which  appears  in  Germany  and  Western  Europe 
in  1034.  Germany  in  those  days  comprised  the  larger  part  of  Europe, 
including  modern  Germany,  Poland,  Austria,  Lorraine,  Burgundy,  and 
Upper  Italy.  In  1056  over  a  million  and  a  half  of  the  inhabitants  in 
the  district  of  Samarcand  and  Bokhara  died  of  plague. 

As  in  the  East  so  in  Europe,  the  11th  century  Avas  characterised  by 

the  occurrence  of  several  devastating:  eiDidemics  of  plague. 
Plague  at  the      „,  ,    ■      ^  •      i^n^   t  -4. 

time  of  the         1  he  worst  m  burope  was  in  1094,  two  years  previous  to 

Crusades  and  ^\^q  commencement  of  the  Crusades.  There  can  be  no 
after. 

doubt  that  plague  appeared  in  Europe  before  the  Crusades, 

although  this  has  been  considered  by  some  the  period  of  its  earliest 
introduction.  The  return  of  the  Crusaders  from  the  Holy  Land,  often 
bringing  the  disease  with  them,  directed  more  attention  to  the  mortality 
which  it  caused  in  several  parts  of  Europe.  With  the  Crusades  in  the 
12th  and  13th  centuries  plague  assumes  a  more  prominent  form  in 
Europe  and  becomes  more  frequent  and  violent  in  Egypt.  In  1167  the 
victorious  army  of  Frederick  the  Red  Beard  is  almost  exterminated  by  it 
in  Italy,  while  in  1270  plague  in  Tunis  decimates  the  army  of  Louis  XI, 
who,  with  his  son,  died  of  the  disease,  while  the  Crown  Prince  Philippe 
was  attacked  and  recovered.  Plague  was  particularly  severe  in  Europe 
in  1294.  Between  then  and  1346  it  prevailed  six  times  in  different 
countries  in  Europe.  But  while  in  Europe  and  Eg}^)t  the  plague 
manifests  itself  with  greater  persistency  and  is  characterised  by  in- 
creasing virulence  and  wider  diffusive  powers,  it  exhibits  in  Irak  and 
Syria  towards  the  close  of  the  13th  century  a  decline,  there  being  no 
epidemics  of  any  gi-eat  magnitude.  The  depopulated  condition  of  these 
countries  brought  about  by  the  loss  of  life  caused  by  the  wars  of  the 
Crusaders,  by  the  invasion  of  the  Mongols,  and  by  a  series  of  destructive 
earthquakes  followed  by  famine,  epidemics,  epizootics  and  plague,  afforded 
small  opportunity  for  further  devastating  plagues.     The  whole  of  this 


CH.  i]  Plague  in  the  Fourteenth  Century  21 

region  seems  to  have  been  in  the  latter  part  of  the  12th  century  and 
the  early  portion  of  the  13th  in  the  vortex  of  violent  disturbances  of 
the  ordinary  course  of  both  natural  and  social  laws. 

Quiescence  of  plague  in  its  old  centres  did  not  prevent  the  gradually  ^ 
The  second         increasing    force    and   diffusiveness    of  the  plague  which 
recorded  pan-     began  in  the  11th  century,  culminating  in  the  14th  century 

Cl6DllC^  l3Lu6r  .  .,.  I'li'T  !• 

called  tiie  m  an  epidemic  or  pandemic  the  like  of  which  for  destruc- 

Biack  Death.  tiveness  there  are  no  historical  records.  The  starting- 
point  of  this  epidemic  is  not  known.  The  Russian  records  place  it  in 
India ;  the  Grecian  in  Scythia ;  the  English  in  the  country  east  of  the 
Indians  and  Turks ;  the  Arabians  in  the  States  of  the  Great  Khan  of 
Tartary  and  in  the  land  of  darkness ;  and  the  Italians  in  Cathay. 

The  very  unsettled  condition  of  the  whole  of  Asia  at  the  time  of 
this  epidemic  and  its  being  practically  a  terra  incognita  are  probably 
explanations  of  the  vagueness  of  contemporary  writers  on  this  point. 
Kublai  Khan's  empire,  extending  from  Hungary  on  one  side  to  the 
coast  of  China  on  the  other,  had  been  divided  auiong  the  Mogul  Tartar 
chiefs  who  fought  among  themselves  for  supremacy.  It  was  under 
these  circumstances  that  the  great  plague  of  the  14th  century  appeared. 
India,  China,  Tartary,  Central  Asia,  and  Russia  had  come  into  closer 
contact  with  Persia  and  Mesopotamia,  not  by  commerce,  but  by  the 
march  of  armies.  That  there  was  a  wide  diffusion  in  some  of  these 
countries  before  it  reached  Europe  can  be  gleaned  froiri  several  authors, 
but  how  long  it  lasted  is  unknown.  Galfridi  Le  Baker  de  Swynebroke 
sets  it  down  at  seven  years.  One  of  the  gateways  by  which 
nopie  one  of       ^^  appears  to  have  entered  Europe  was  by  Constantinople, 

the  gateways  attacking  that  city  in  1347,  the  infection  having  been 
by  which  the  .  . 

pandemic  carried  from  the  Crimea  and  the  Volga,  where  the  disease 

entered  ^^^^  then  raging:.     Nicephorus  Greeforas  thus  describes  it : 

Europe.  ft     &  i  o 

"  Now  about  this  time  a  deadly  and  pestilential  disease 
swooped  down  upon  the  world.  It  began  with  the  Scythians  and  at 
Lake  Maeotis  and  the  mouth  of  the  Don,  in  the  very  beginning  of  the 
spring  and  continued  through  all  that  year,  passing  from  place  to  place 
and  devastating,  in  this  wise,  only  the  sea  coasts,  town  and  country 
alike,  as  well  our  territories  as  all  those  which  stretch  without  a  break 
as  far  as  Cadiz  and  the  Pillars  of  Hercules.  But  when  the  second  year 
came  it  passed  also  on  to  the  Islands  of  the  Aegean.  Then  it  attacked 
the  Rhodians  and  the  people  of  Cyprus  also,  and  all  that  inhabit  all  the 
other  islands.  The  disease  affected  alike  men  and  women,  rich  and  ^ 
poor,  young  and  old ;   to  put  the  matter  in  a  word  it  spared  neither 


'22  Historn  and  Distribution  of  Plagne        [part  i 

rank  nor  ago.  Many  houses  were  stripped  entirely  of  their  inhabitants 
in  one  day,  or  sometimes  in  two,  since  no  one  was  able  to  render  the 
sufferers  help,  no  one  either  of  the  neighbours  or  of  those  who  were 
connected  by  blood  or  any  relationship.  Nor  was  it  mankind  alone 
that  the  plague  thus  harassed  as  with  a  scourge,  but  all  (jther  animals 
which  dwelt  with  or  associated  with  human  beings  who  took  the  disease, 
dogs,  and  horses  and  fowls  as  well,  and  even  the  mice  that  lived  within 
the  walls  of  their  houses.  The  symptoms  of  the  plague  which  declared 
themselves  signs  foreboding  a  sudden  death  were  the  following:  A 
swelling  about  the  upper  parts  of  the  thighs  and  the  arms,  and  accom- 
panying it  an  effluxion  of  blood.  This  in  some  cases  on  the  very  same 
day  carried  off  from  the  present  life,  whether  sitting  or  walking,  those 
who  had  been  stricken  by  it.  Andronicus,  among  others,  the  younger 
of  the  king's  sons,  died  of  it." 

There  is  nothing  in  this  description  to  indicate  that  the  plague  was 
The  course  of     *^^*^  '^  different  type  from  that  which  had  previously  pre- 

the  pandemic  vailed  except  perhaps  its  virulence.  The  Arabian  author 
a,s  d6scrib6(i  x      i  j. 

by  an  Arabian  Ibn  Wardy  traces  the  course  of  the  plague  in  a  more 
author.  definite   manner   than  Nicephorus   Gregoras.     He  relates 

that  it  first  made  its  appearance  in  "the  land  of  darkness',"  that  it  then 
penetrated  to  China  and  India,  turned  thence  to  the  land  of  Usbekir 
and  to  Transoxiania,  reached  Persia,  depopulated  (.^entral  Asia,  Crimea, 
and  Byzantium,  then  Cyprus  and  the  Islands.  The  epidemic  then 
appeared  in  Egypt,  depopulated  Cairo  and  Alexandria,  and  even  reached 
Upper  Egypt,  and  crept  in  a  westerly  direction  along  the  African  coast 
to  Barca.  On  the  other  side  the  epidemic  from  Egypt  reached  the 
ports  of  Gaza  and  Asoalon,  invaded  Syria,  and  travelling  coast  wards  and 
inland,  attacked  Jerusalem,  Damascus,  Antioch,  and  Aleppo,  and  most 
of  the  intervening  towns,  also  those  of  Asia  Minor.  Ibn  Batuta  was  in 
Damascus  in  1348  on  his  return  journey  from  China,  and  he  describes 
the  havoc  which  the  plague  caused  in  that  city  at  the  time  of  his  visit. 

It  is  possible  that  the  great  epidemic  of  the  14th  century  had  its 
origin  in  its  old  endemic  centres  in  Mesopotamia  and  Kurdistan,  and 

1  The  kingdom  of  Kiptchak,  whose  capital  was  Surai,  was  held  by  Arab  writers  to  be 
the  northern  limit  of  the  habitable  world,  and  as  stated  by  Yule  {The  Book  of  Marco  Polo 
the  Venetian,  by  Col.  Henry  Yule,  C.B.,  vol.  i.  p.  6)  in  his  Marco  Polo,  Bolghar  was  the 
capital  of  the  region  sometimes  called  Great  Bulgaria,  by  Abulfeda  Immer  Bulgaria,  and 
stood  a  few  miles  from  the  left  bank  of  the  Volga  in  latitude  about  54°  54'  and  90  miles 
below  Kazan.  The  old  Arab  writers  regarded  it  as  nearly  the  limit  of  the  habitable 
world  and  told  wonders  of  the  cold,  the  brief  summer  nights,  and  the  fossil  ivory  that  was 
found  in  its  vicinity. 


CH.  l] 


Plague  in  the  Fourteenth  Century 


23 


that  in  its  general  extension  north,  east,  south  and  west  it  reached 
the  Volga  by  routes  similar  to  those  which  it  has  taken  in  more  modern 
times.  There  was  intercourse  between  Persia  and  southern  Russia,  and 
when  it  was  not  by  commerce  it  was  frequently  by  the  march  of  armies 
in  the  time  of  war.  Marco  Polo  relates  that  while  his  father  and  uncle 
were  staying  with  Barca  Khan  at  Bolghar  there  broke  out  a  war 
between  Barca  and  Alan  the  Lord  of  the  Tartars  of  the  Levant,  and 
great  hosts  were  mustered  on  either  side.  But  in  the  end  Barca  the 
Lord  of  the  Tartars  of  the  Ponent  was  defeated,  though  on  both  sides 
there  was  great  slaughter. 

It  would  serve  no  useful  purpose  to  follow  up  this  pandemic  into 
the  different  countries,  provinces  and  towns  in  Asia,  Africa, 
and  Europe  which  it  successively  ravaged.  In  the  course 
of  three  years  it  passed  over  the  whole  of  Europe  and 
was  unique  in  the  enormous  destruction  of  life  which  it 
caused,  it  being  estimated  that  quite  a  fourth  of  the 
population  perished.  This  great  mortality  was  not  because  the  plague 
caused  in  any  one  place  more  deaths  than  many  of  the  previous  or  later 
epidemics  of  the  same  disease,  but  because  of  its  widespread  nature. 
Never  before  had  it  shown  such  diffusive  qualities,  or  attacked  so  many 
countries  one  after  the  other.  Hecker^  gives  the  mortality  of  some 
European  towns  which  he  has  specially  collected.     It  is  as  follows : 


Pandemic 
distin^ished 
by  its  rapid 
spread  and 
destructive- 
ness. 


Towns 

Deaths 
from  Plague 

Florence 

60,000 

Venice 

100,000 

Marseilles    (in  1 
one  month)  f 

1G,000 

Siena 

70,000 

Paris 

50,000 

St  Denys 

14,000 

Avignon 

60,000 

Towns 
Strasbiirg 
Liibeck 
Basle 
Erfurt 
Weimar 
Limburg 
London 
Norwich 


Deaths 
from  Plague 

16,000 

9,000 
14,000 
16,000 

5,000 

2,500 

100,000 

51,100 


A  special  interest  attaches  to  the  epidemic  at  Avignon  as  an  account 
Guy  de  Chau-     ^^  i^  ^^  given  by  a  medical  man,  Guy  de  Chauliac,  which  is 
very  exceptional  for  these  early  plagues.    Guy  de  Chauliac 
says:    "  ^The  plague  commenced  with   us   in  January,  it 
continued  seven  months  during  which  time  it  appeared  in 


liac's  descrip- 
tion of  the 
pla^e  at 
Avignon. 


^  The  Epidemics  of  the  Middle  Ai)e^,  by  J.  F.  C.  Hecker,  M.D.,  translated  by  B.  G. 
Babington,  M.D.,  F.R.S. 

'^  La  Grande  Chirurgie  de  Maistre  Guy  de  Chauliac,  par  M.  S.  Mingelou  Saule, 
Traite  ii.  cap.  v. 


'24:  Histonj  and  Distribution  of  Plague        [part  i 

two  forms.     During  the  first  two  months,  it  was  accompanied  with  a 

continuous  fever  and  with  a  coughing  of  blood.     All  who  were  attacked 

died  in  three  days.     During  the  other  months  the  continuous  fever  was 

accompanied  with  tumours  and  boils,  which  appeared  in  the  external 

parts  of  the  body  chiefly  in  the  armpits  and  in  the  groin.     Those  who 

were  thus  attacked  died  in  five  days.     The  disease  was  so  severe  and  so 

contagious,  especially  that  which  was  attended  by  coughing  of  blood, 

that  it  was  contracted  not  onl}-  by  visiting  and  living  together  with  the 

sick,  but  by  being  in  their  presence,  so  that  people  died  without  service 

or  attendants,  men  were  buried  without  priests  and  without  religious 

rites,  the   father  abandoned  the  son  and  the  son  approached  not  the 

father;    charity  was  dead  and  every  hope  lost."^ 

Few  parts  of  Europe  seem  to  have  escaped.     The  epidemic  reached 

Le  Baker  de        England  in  the  latter  part  of  1348,  and  is  thus  described 

swynebrokes     by  Le  Baker  de  Swynebroke:  "  -In  the  year  of  Christ  1349^ 

account  of  .  c     ^       ^r-      ■,  ■ 

the  epidemic      m  the   23rd  year  of  the  King's  reign,  a  general  plague 

in  England.  spreading  from  the  East  of  the  Indians  and  Turks,  in- 
fecting a  half  of  our  habitable  world,  ravaged  with  such  havoc  Saracens, 
Turks,  Syrians,  people  of  Palestine  and  then  the  Greeks  that,  compelled 
by  terror,  they  determined  to  accept  the  faith  and  sacraments  of  Christ, 
hearing  that  the  Christians  on  our  side  the  sea  were  not  afraid  of  the 
death  that  came  upon  them  more  frequently  than  was  wont.  At  length 
the  dreadful  calamity  passing  in  succession  the  parts  beyond  the  Alps 
and  from  there  to  the  west  of  France  and  Germany  in  the  7th  year 
after  its  outbreak  arrived  in  Europe.  And  at  first  it  carried  off  almost 
all  the  inhabitants  of  the  seaports  in  Dorset,  and  then  those  living 
inland,  and  from  there  it  raged  so  dreadfully  through  Devon  and 
Somerset  as  far  as  Bristol  that  the  men  of  Gloucester  refused  those  of 
Bristol  entrance  to  their  country,  everyone  thinking  that  the  breath  of 

^  "In  couuection  with  this  epidemic  it  is  interesting  to  note  that  the  country  people 
in  France  dwelt  mostly  in  one-storied  huts  having  mud  or  clay  walls  and  thatched  roofs. 
Windows  were  the  exception.  Over  the  door  was  usually  an  opening  for  air  and  light, 
which  also  served  as  an  outlet  for  the  smoke  from  the  brushwood  fire.  The  sleeping- 
places  were  dark,  airless  recesses,  in  which  the  people  having  divested  themselves  of  all 
clothing  rested  upon  straw  mattresses  or  sometimes  on  feather  beds.  Batliing  w^as 
common  and  much  used,  especially  among  the  lower  classes,  and  even  small  villages 
had  their  public  bath  places."  (T/it'  Great  Pestilence,  a.d.  1348-9,  by  Francis  Aidau 
Gasquet,  D.D.,  1893.) 

*  Chronicon  Gal/ridi  Le  Raker  de  Swynebroke,  edited  by  Edward  Maunde  Thompson, 
1889. 

3  Le  Baker  de  Swynebroke  counted  the  year  from  Michaelmas,  so  that  the  early  part 
of  1349  with  him  was  actually  the  latter  part  of  1348. 


CH.  i]  Placjue  in  the  Fourteenth  Century 


'10 


those  who  lived  amongst  people  who  died  of  plague  was  infectious. 
But  at  last  it  attacked  Gloucester,  yea  and  Oxford  and  London,  and 
finally  the  whole  of  England  so  violently  that  scarcely  one  in  ten  of 
either  sex  was  left  alive.  As  the  graveyards  did  not  suffice  fields  were 
chosen  for  the  burial  of  the  dead.  The  Bishop  of  London  bought  the 
croft  in  London  called  '  No  man's  land,'  and  the  Lord  Walter  de  Magne 
that  which  is  called  '  The  New  Church  Hau,'  where  he  founded  a  house 
of  persons  in  religion  to  bury  the  dead.  All  pleas  in  the  King's  Bench 
and  common  pleas  of  necessity  were  stopped.  Very  few  nobles  died  of 
it.  Among  them  were  Lord  John  of  Montgomerie,  Captain  of  Calais, 
and  the  Lord  of  Clistele ;  they  died  in  Calais  and  were  buried  in 
London  in  the  Church  of  the  Carmelite  Brothers  of  Blessed  Mary.  A 
countless  number  of  common  people  and  a  host  of  monks  and  nuns  and 
clerics  as  well,  known  to  God  alone,  passed  away.  It  was  the  young  and 
strong  that  the  plague  chiefly  attacked.  The  old  and  feeble  it  commonly 
spared.  Scarcely  anyone  dared  to  touch  the  sick ;  the  healthy  fled 
from  relics  of  the  dead,  precious  then  and  now,  as  if  they  were  infectious. 
One  day  men  were  as  happy  as  could  be,  and  on  the  morrow  they  were 
found  dead. 

"Abscesses  suddenly  breaking  out  in  different  parts  of  the  body 
tortured  them ;  they  were  so  hard  and  dry  that  when  they  were  cut 
hardly  any  humour  flowed  from  them :  many  persons  got  over  them  by 
means  of  incision  or  by  long  patience.  Others  had  small  black  pustules 
spread  all  over  the  skin,  and  of  these  very  few,  nay  rather  scarcely  one 
recovered.  This  great  pestilence,  which  began  at  Bristol  on  the  feast  of 
the  Assumption  of  the  glorious  Virgin  and  in  London  about  the  feast 
of  St  Michael,  raged  for  a  whole  year  in  England  so  terribly  that  it 
cleared  many  country  villages  entirely  of  every  human  being. 

"  While  this  great  calamity  was  devastating  England,  the  Scots 
rejoicing  thought  that  they  would  obtain  all  they  wished  against  the 
English,  and  at  the  time  blaspheming  were  wont  from  sheer  wantonness 
to  perjure  themselves  'by  the  vile  death  of  the  English.'  But  sorrow 
following  on  the  heels  of  joy,  the  sword  of  the  anger  of  God  departing 
from  the  English  drove  the  Scots  to  frenzy  through  leprosy  no  less 
than  it  had  done  the  English  through  abscesses  and  pustules.  In  the 
following  year  it  ravaged  the  Welsh  as  well  as  the  English :  and  at  last, 
setting  sail,  so  to  speak,  for  Ireland  it  laid  low  the  English  living  there 
in  great  numbers,  but  scarcely  touched  at  all  the  pure  Irish  who  lived 
amongst  the  mountains  and  on  higher  ground  until  the  year  of  Christ 
1357,  when   it   unexpectedly  and   terribly  destroyed   them  also  every- 


26  History  and  Distribution  of  Plague       [part  i 

where."  ^  The  important  features  in  this  plague  visitation  were  its 
rapid  and  wide  diffusion,  its  c()in])aratively  short  duration,  the  virulence 
of  the  cases  with  pustules,  the  large  proportion  of  cases  affecting  the 
lungs  with  spitting  of  blood,  and  the  great  contagiousness  of  the 
pneumonic  form.  Apart  from  its  attacking  the  lungs  the  virulence  and 
diffusiveness  of  the  disease  in  its  other  manifestations  seem  to  have 
been  very  marked.  Diffusiveness  may  characterise  one  epidemic  and 
virulence  another,  but  in  this  epidemic  both  qualities  were  united  in  an 
exceptionally  high  degree. 

This  destructive  epidemic  of  the  14th  century  formed  the  climax  of 
that   expanding  activity  of  plague  which  began  in  the 
mh^ieSi**^^     11th  century  and  which  continued  at  intervals  to  manifest 
and  17th  itself  in  a  widespread  manner  until  the  end  of  the  17th 

century.  In  the  15th,  16th,  and  17th  centuries  there  were 
frequent  outbursts  and  epidemics  in  Europe,  Asia,  and  Africa  more  or 
less  limited  in  their  extent. 

Heberden-,  who  ascribes  the  prevalence  of  plague  to  the  physical 
and  political  miseries  of  the  nations  of  Europe  during  these  centuries, 
gives  a  list  of  some  of  the  more  important  places  on  the  Continent 
attacked  with  plague  in  the  course  of  this  period.  Dresden  was  attacked 
with  plague  in  the  years  1504-5,  1511-12,  1521,  1535-36,  1547, 
1563-64,  1571-72,  1585-86,  1591-92,  1607,  1627-28,  1632-3-4-5-6-7. 

"In  1502  the  disease  was  at  Brussels;  1517  at  Verona;  1525  in 
Germany;  1531  and  1534  in  France;  1539  in  Switzerland;  1542  at 
Breslau ;  1550  at  Basel:  between  1550  and  1553  it  spread  itself 
successively  over  almost  all  the  habitable  world;  1559  it  was  in 
Holland;  1563  it  was  in  Germany,  and  again  in  1566;  1564  in  Savoy; 
1566  and  1568  at  Milan  ;  1568  at  Paris  ;  1572  at  Basel ;  1575  at  Milan ; 
1576  at  Venice;  1580  at  Marseilles;  1593  it  was  in  Holland  and  the 
Low  Countries;  1596  and  1597  in  Germany;  1603  it  was  again  in 
Holland,  also  in  1609,  and  in  the  latter  part  of  the  year  in  Denmark; 
1618  at  Bergen;  1619  in  Denmark;  1622  at  Amsterdam,  where  it 
continued  for  eight  years;  1623  it  was  at  Montpellier;  1625  at  Leyden, 

^  The  effect  in  England  of  this  severe  visitation  of  plague  was  as  in  other  countries 
the  disorganisation  of  the  social  system  which  recjuired  many  years  for  its  recovery  and 
reconstruction.  For  instance  it  was  not  until  200  j'ears  later  that  tillage  was  revived  in 
England  to  a  similar  extent.  This  improvement  began  in  the  time  of  Elizabeth  (The 
Growth  of  English  Induatrn  in  Modern  Times,  lib.  ii.  p.  100,  by  W.  Cunningham,  D.D., 
1903). 

2  Observatioiis  on  the  increase  and  decrease  of  different  diseases,  and  particularly  of  the. 
plague.     By  Wm.  Heberden,  Juu.,  M.D.,  F.R.S. 


CH.  i]    The  Fifteenth,  Sixteenth,  Seventeenth  Centuries      27 

in  Denmark,  and  in  Germany;  1628  it  was  at  Lyons;  1629  and  1630  at 
Montpellier;  1631  at  Dijon;  in  1630  it  was  besides  in  Denmark  and  at 
Christiania  in  Norway;  and  at  Parma,  Verona  and  other  parts  of  Italy; 
from  1633  to  1637  it  was  in  the  Netherlands,  and  in  the  latter  year 
at  Prague;  in  1649  more  than  200,000  persons  are  said  to  have  perished 
by  this  disease  in  the  southern  provinces  of  Spain;  1649  and  1650  it 
prevailed  at  Marseilles;  1650  it  was  also  in  Ireland;  1652  at  Cracow; 
1653  in  Poland  and  Prussia;  1654  at  Copenhagen;  1655  at  Amsterdam; 
and  in  the  course  of  the  same  year  and  the  three  following  it  was  in 
many  places  in  the  south  of  Europe ;  1660  it  was  in  Scotland ;  1663  and 
1664  at  Amsterdam  and  Hamburg;  1668  in  Flanders;  1670  in  Italy; 
1679  at  Vienna;  1680  at  Leipsic ;  1684  in  Norway;  1685  at  Leghorn. 
In  1622  the  mortality  by  the  plague  at  Amsterdam  (at  that  time  equal 
to  about  one-third  of  London)  was  4000 ;  in  1623,  6000  ;  in  1624,  12,000  ; 
1625,  6800;  in  1626,  4400;  1627,  4000;  in  1628,  4500.  Felix  Platerus, 
physician  at  Basel,  in  Switzerland,  about  1580,  gives  an  account  of  seven 
pestilential  fevers  which  afflicted  that  country  in  the  space  of  70  years. 
Thomas  Bartholin  mentions  five  that  raged  in  Denmark  in  his  time 
(1660),  and  Forestus  relates  that  in  his  time  (1570)  the  plague  was 
frequent  at  Cologne  and  Paris ;  and  refers  the  cause  to  the  multitude  of 
the  inhabitants  and  the  nastiness  of  the  streets. 

"  By  another  account  Paris  is  said  to  have  been  infected  eight  times 
between  the  years  1480  and  1590;  in  1607  two  hospitals  of  reserve, 
St  Louis  and  St  Anne,  were  erected  on  purpose  to  receive  patients 
in  time  of  plague  or  other  great  calamities.  They  were  opened  on 
account  of  the  plague  in  1619,  1631,  1638,  1662  and  1668,  since  which 
that  disease  has  been  unknown  there.  We  are  informed  that  about  the 
same  time  Paris  was  paved  and  the  streets  were  widened,  and  the  city 
began  to  be  kept  cleaner." 

During  this  period  plague  also  prevailed  frequently  in  Britain.    The 

most  important   outbreaks  are   described  by  Creighton  in  his  history 

of  epidemics  of  Britain.     Many  of  them  are   ascribed   to   importation 

from  the  Continent.     There  is  little  doubt  that  the  eastern  coast  was 

more  frequently  affected  than  any  other  part  of  the  country.     Whether 

the  endemicity  was  kept  up  by  communications  with  Holland  cannot 

now  be  determined,  but  it  is  not  an  unlikely  explanation. 

London  in  the     London  itself  was  never  long  free  from  plague,  though 

letii  and  i7tii  severe  epidemics  were  infrequent.  Some  valuable  notes  on 
centiiries. 

the  occurrence  of  plague  collected  by  Mr  Baldwin  Latham 

make  this  clear.      In   the  course   of  136  years   plague   deaths   were 


28  Histonj  and  Dixfribittion  of  Plague        [part  i 

recorded  in  London  in  no  fewer  than  84  years,  but  only  six  of  these 
years  were  characterised  by  severe  epidemics.  The  six  years  and  the 
number  of  plague  deaths  recorded  are : — 


Year 

Number  of 
Plague  Deaths 

1563 
1592-93       . 

23,000 

22,167,  according  to  Creighton  15,003 

1603 
1625 

36,269 
35,417 

1636 

10,400 

1665 

()8,596 

Notes  of  the  Occurrence  of  Plague  in  London  and  some  other  places  in 
England  since  the  year  1543,  and  returns  of  ]ilague  mortality  in 
London,  collected  hy  Mr  Baldivin  Latham,  M.I.C.E.,  from  various  sources, 
and  mainly  from  the  annual  Records  of  Weddings,  Christenings,  and 
Burials,  kept  in  pursuance  of  orders  passed  hy  Thomas  Cromwell,  Lord 
Privy  Seal,  in  September,   1538'. 

1543  Plague  in  London.     Lanquette's  Chronicle. 

1548  Pestilence  in  London.     Stow's  Annals. 

1551  Sweating  sickne.s.s  in  London.    Lanquette'.s  Chronicle  and  Fabian's  Chronicle. 

1552  Plague  prevalent.     History  of  the  weather. 
1558  Plague  in  King's  Lynn.     Richards'  King's  Lynn. 

1562  Plague   cau.sed   20,136  deaths.     Bills   of  Mortality,  London.     Brought  by 

.soldiers  from  the  Continent.     History  of  the  weather. 
1562-3  City   and   Suburbs    of  London  :    Burials    23,630  — Plague   burials   20,136. 
Maitland's  London,  page  736. 

1563  23,000  persons  died  in  London  of  plague  between  6th  April  and  last  day 

of  November.     Lanquette's  Chronicle. 

1564  Plague  not  fully  ceased  in  London.     Stow's  Annals. 
1569       Plague  in  London.     Stow's  Annals. 

1574  Plague  in  the  City.     Maitland's  London. 

1575  Plague  in  King's  Lynn.     Mackerell's  King's  Lynn. 

1581-2  Between  28th  Dec,  1581,  and  27th  Dec,  1582,  died  of  plague  in  London, 
6,930.     Maitland's  London. 

1587  Plague  raged  in  King's  Lynn.     Richards'  King's  Lynn.     Burials  in  Leeds 

tripled  by  the  plague.     Annals  of  Yorkshire.     Plague  rife, — said  to  be 
due  to  famine.     History  of  the  weather. 

1588  Plague  raged  in  King's  Lynn.     Richards'  King's  Lynn. 

1589  Plague  in  Newcastle-on-Tyne.     Newcastle  Record. 

1592*     Plague  in   London.     From   March  to   December,  25,886   persons  died,   of 
whom  11, .503  died  of  i)lague.     Graunt. 

1  The  Recent  Epidemics  of  Plague  in  Bombay.     Paper  read  before  the  Geographical 
Society  of  Manchester,  the  19tb  May,  1898.     By  H.   M.  Birdwood,  C.S.I.,  LL.D. 
*  Excessive  drought. 


CH.  l] 


Plague  in  London 


29 


1593 

1594* 

1595 

1603 
1604 

1605 

1606 

1607 

1608 

1609 

1610 

1611 

1612t 

1613 

1614 

1615 

1616 

1617 

1618 

1619 

1620 

1621 

1622 

1623 

1624 

1625 

)) 
1626 
1627 
1628 
1629 
1630 
1631 
1632 
1633 
1634 
1635 
1636J 
1637§ 
1638 
1639 


Plague  in  London.     17,844  died,  of  whom  10,662  died  of  plague,  and  the 

christenings  were  4,021. 
No  record  for  London.     Very  healthy  at  Croydon,  also  in  County  parish. 

(Referred  to  by  Graunt.) 
No  record  for  London.     Great  dearth  in  England.     No  record  for  London 

until  1603. 
Burials  for  London  and  Liberties,  42,042.     Plague  burials,  36,269. 
Burials,  London,  5,219  ;  Plague  burials,  896.     Plague  raged  in  many  country 

places. 

Plague, 


Burials,  London, 


Burials  within  walls, 
Burials,  London, 


6,391 

7,920 

8,022 

9,020 

11,785 

9,087 

7,343 

7,842 

7,519 

7,389 

7,887 

8,072 

8,286 

9,614 

8,008 

9,712 

8,123 

8,959 

11,112 

12,210 

54,265 

14,340 

7,535 

7,715 

7,743 

8,814 

10,554 

8,358 

9,439 

8,428 

10,865 

10,865 

23,359 

11,763 

13,624 

9,862 


444 

2,124 

2,352 

2,262 

4,240 

1,803 

627 

64 

16 

22 

37 

9 

6 

18 

9 

21 

11 

16 

17 

11 

35,417 

9,197 

134 

4 

3 

nil 

1,317 

274 

8 

nil 

1 

nil 

10,400 

3,082 

363 

314 


Wet  year. 
Great  drought. 


t  Tempests,  Oct.,  Nov.,  and  Dec. 
§  Summer  hot  and  droughty. 


Drought. 


30 


Historji  (ukI  Disfrihfffioii  of  Plaf/ne        [part  i 


1640  Burials,  London,  ...  12,771 

1641  „  ...  18,291 

1642  „       ...  12,167 

1643  „  ...  13,202 

1644  „  ...  10,933 

1645  „  ...  11,479 

1646  „  ...  13,532 

1647  „  ...  14,059 

1648  „  ...   9,996 
1649*  „  ...  10,532 

1650  „  ...   8,581 

1651  „  ...  10,773 

1652  „  ...  12,539 

1653  „  ...   9,083. 

1654  „  ...  13,126 

1655  „  ...  11,409 

1656  „  ...  13,752 

1657  „  ...  12,434 

1658  „  ...  14,993 

1659  „  ...  14,756 
1660t  „  ...  15,118 

1661  „  ...  19,771 

1662  „  ...  16,554 

1663  „  ...  15,356 

1664  „  ...  18,297 
1665+  „  ...  97,306 

1666  „  ...  12,738 

1667  „  ...  1.5,842 

1668  „  ...  17,278 

1669  „  ...  19,432 

1670  „  ...  20,198 

1671  „  ...  15,729 

1672  „  ...  18,230 

1673  „  ...  17,504 

1674  „  ...  21,201 

1675  „  ...  17,214 

1676  „  ...  18,732 

1677  „  ...  19,067 

1678  „  ...  20,678 

1679  „  ...  21,730 

1680  „  ...  21,053 

There  are  no  fui-tlior  records  of  the  plague. 

Many  of  the  epidemics  on  the  Continent 
former  outbreak.s  in  the  same  locality  or  were 

brought   from   neighbouring   States.  They   we 

*  Commonwealth  commenced.  f  Charles  II. 


Plague,     1,450 
3,067 
1,824 
996 
1,492 
1,871 
2,436 
3,597 
611 
67 
15 
23 
16 
6 
16 
9 
6 
4 
14 
36 
14 
20 
12 
9 
6 
68,596 
1,998 
35 
14 
3 
nil 
5 
5 
5 
3 
1 
2 
2 
5 
2 
7iil 


were  recrudescences  of 

caused  by  the  infection 

re    manifestations    of  a 

J  Hot  and  dry. 


CH.  i]  Plagiie  and  Commerce  31 

disease  which  had  become  more  or  less  endemic  in  some  portion  of  the 
country  in  which  they  appeared,  but  in  addition  to  these 
cences  and  there    were    apparently   now    and    again   great    epidemic 

v^Ve™from  waves  spreading  in  every  direction  from  the  old  endemic 
old  endemic  areas  then  in  possession  of  the  Turks  and  the  Tartars. 
Some  conditions  which  have  not  yet  been  recognised 
imparted  to  the  disease  an  exceptional  amount  of  diffusibility  and 
infectivity  which  enabled  it  to  advance  irresistibly  along  the  ordinary 
trade  routes  of  travel  and  to  become  epidemic  in  most  places  it  visited. 
Plague  is  not  the  only  disease  which  has  displayed  these  characters. 
Cholera  and  influenza  in  their  visitations  during  the  19th  century 
comported  themselves  in  a  similar  manner.  The  epidemics  of  plague 
gradually  became  less  frequent  even  in  those  places  most  exposed  to  its 
invasion.  There  were  eleven  epidemics  in  Marseilles  in  the  16th  century, 
only  two  in  the  17th  century  and  only  one  in  the  18th  century.  In 
these  subsequent  visitations  the  all-pervading  destruction  which  dis- 
tinguished the  1348  pandemic  was  absent,  though  at  times  some 
circumscribed  areas  would  suffer  from  as  virulent  if  not  a  more  virulent 
type  of  plague.  This  was  the  case  in  1437  in  Cairo,  which  was  almost 
depopulated  ;  in  1576  in  Venice,  which  lost  70,000  of  its  inhabitants;  and 
in  the  same  year  in  Moscow,  which  lost  200,000  of  its  inhabitants;  in  1656 
in  Naples,  which  lost  300,000  of  its  inhabitants ;  and  in  Rome,  which  lost 
in  the  same  year  145,000.  Genoa  also  lost  60,000.  There  died  in 
London  of  plague  in  1665  nearly  70,000  persons. 

Unless  maintained  by  fresh  importations  from  the  East  the  endemic 
areas  in  Europe  never  seem  to  have  long  retained  their  endemicity. 
There  were  many  facilities  for  fresh  importations. 

From  the  10th  to  the  16th  century  the  Venetians  possessed  almost 
Plague  and  a  monopoly  in  the  commerce  between  the  East  and  the 
commerce.  West,  their  only  rivals  being  other  Italian  States,  such 

as  Genoa  and  Florence.  Italy,  more  particularly  Venice,  was  practically 
the  gateway  through  which  the  produce  of  India,  China,  and  Persia 
passed  into  Europe.  The  merchandise  was  brought  overland  in  caravans 
to  the  shores  of  the  Mediterranean  or  Black  Sea,  and  thence  by  ships  to 
the  Italian  State,  which  was  the  great  distributing  centre  for  Europe. 
On  their  way  through  Mesopotamia  and  neighbouring  countries  the 
caravans  passed  through  endemic  areas  of  plague.  The  great  trade 
routes  from  Venice  to  the  north-west  of  Europe,  to  the  Baltic  and  to  the 
North  Sea,  were  not  by  sea  but  by  land  through  central  Germany.  Tht; 
Hanseatic  League,  that  great  confederacy  of  towns  for  the  furtherance 


32  Historii  and  DistrihiUion  of  Plaijue        [part  i 

and  protection  of  trade  on  tlic  north,  was  the  connecting  link  between 
Venice  and  the  north.  It  carried  on  an  immense  trade  with  Venice. 
The  great  commercial  cities  of"  Bremen,  Dantzic,  Lllbeck,  Hamburg, 
Cracow,  Ratisbon,  Augsburg,  Nuremburg,  Frankfort,  and  other  towns 
were  connected  by  these  land  routes ;  and  periodical  fairs  were  held  in 
them  to  which  merchants  Hocked  from  all  parts,  bringing  their  goods 
and  exchanging  them  for  others.  They  afforded  facilities  if  plague  were 
present  for  its  extension.  During  this  period  plague  appears  to  have 
prevailed  periodically  and  with  great  persistence  in  Europe,  being  main- 
tained by  fresh  incursions  of  the  disease  from  the  East  brought  in  the 
train  of  armies  or  of  commerce.  Venice  alone  in  the  course  of  six 
centuries  from  900  to  1500  suffered  from  63  epidemics  of  plague.  The 
Venetians  were  the  first  to  learn  that  there  was  a  connection  between 
merchants  and  merchandise  coming  from  or  passing  through  countries 
affected  with  plague  and  the  conveyance  of  that  disease  to  healthy 
localities,  and  for  self-protection  they  were  the  first  to  practise  against 
ships  from  Alexandria  and  the  Levant  preventive  measures  in  the  form 
of  quarantine,  which  was  based  on  the  medical  doctrines  of  the  day. 
Venice  established  a  Lazaretto  in  1403  on  the  island  of  8te  Marie  of 
Nazareth,  and  was  followed  in  1467  by  Genoa  and  by  Marseilles  in 
1526,  both  towns  having  considerable  commerce  with  the  East.  The 
effect  of  the  introduction  of  quarantine  in  these  three  ports  was  how- 
ever small  compared  to  that  which  followed  the  decline  of  the  Venetian 
trade  in  consequence  of  the  discovery  of  America  and  of  the  sea  route 
to  the  East  Indies  round  the  Cape  of  Good  Hope. 

These  two  great  discoveries  at  the  end  of  the  15th  and  the 
beginning  of  the  16th  century  were  gradually  to  effect  a  great  change  in 
commerce,  one  of  which  was  the  transference  of  a  commerce  which  was 
exclusively  overland  or  coasting  to  a  sea  commerce,  and  the  other  was  to 
change  the  routes  of  international  commerce  so  as  to  deprive  the 
Italian  States  of  the  monopoly  which  they  had  possessed  for  several 
centuries.  Venice,  the  principal  mart  of  the  products  of  the  Orient,  was 
not  long  in  discovering  the  injurious  effect  likely  to  arise  from  the 
discovery  of  the  Portuguese,  and  in  the  16th  century  its  Government 
made  advances  to  the  Portuguese  with  the  object  of  buying  everything 
brought  by  the  Portuguese  from  the  East.  These  proposals  were 
rejected.  Trade,  however,  seldom  becomes  suddenly  diverted  from  its 
customary  routes,  and  though  much  of  the  commerce  of  the  East  was 
shifted  to  Lisbon,  a  great  deal  remained  in  the  Mediterranean,  shared 
by    Italy   and    France;    and   it    was   only   at   the   beginning    of    the 


CH.  i]  Retrocession  of  Plague  33 

17th  century,  when  Venice  lost  its  power  in  the  Levant,  and  when  the 
Netherlands  and  England  began  to  take  the  place  of  Portugal  and 
Spain,  by  which  the  commercial  activities  of  Europe  with  the  East  were 
transferred  to  the  ports  in  the  North  Sea,  that  the  roads  northwards 
from  Venice  and  Marseilles  became  no  longer  the  routes  by  which  the 
produce  of  the  East  was  carried  to  northern  towns.  The  Hanseatic 
League  came  to  an  end  about  164L  The  Thirty  Years'  War,  from 
1618  to  1648,  which  had  been  the  means  of  spreading  plague  largely  in 
Europe,  had  practically  destroyed  the  mercantile  intercommunications 
between  the  North  and  the  South,  and  at  the  same  time  had  destroyed 
the  League. 

France,  which  was  the  only  other  country  having  direct  dealings 
with  the  Levant  through  Marseilles,  was  in  a  state  of  misery  and 
disorganisation  during  the  first  half  of  the  17th  century,  and  was 
afflicted  not  only  with  plague,  but  also  with  fiimine.  Its  commerce 
with  the  Levant  and  North  Africa  was  brought  to  its  lowest  point 
on  account  of  piracy  in  the  Mediterranean  and  the  unfriendly  attitude 
of  the  Turk.  A  new  route  to  Persia  through  the  Caspian  Sea, 
Astrakhan,  Novgorod  and  Narva,  was  accordingly  opened  out  in  1630, 
by  which  for  a  considerable  time  the  produce  of  Persia  and  the  East  was 
conveyed  to  France. 

With  the  altered  circumstances  there  were  fewer  facilities  for  the 

importation    of    plague,    and    after   the    great    outbreaks 

cessation  of        between   the  fifties  and  eighties  in  the  17th  century,  of 

plague  in  which  the  plague  of  London  in  1666  with  its  70,000  deaths 

Western  ,  i  -ni- 

Europe  at  the     lormed  a  part,  plague  rapidly  disappeared  from  the  whole 

end  of  the  q£  Western  Europe.     The  last  epidemic  in  Ireland  was  in 

ITth  century.  ^  ^ 

1650,  in  Denmark  1654,  in  Sweden  1657,  in  Italy  1657,  in 

the  Netherlands  and  Belgium  1664-66,  in  England  1666,  in  Switzerland 
1667-68,  in  France  1667-68,  in  Western  Germany  1667-68,  in  Spain 
1677-81  and  in  Eastern  and  Southern  Germany  in  1679-81.  The 
cessation  of  plague  in  all  these  countries  in  so  short  a  time  is  a 
remarkable  epidemiological  fact.  There  may  have  been  and  probably 
were  other  powerful  causes  at  work,  particularly  in  connection  with  the 
natural  history  of  the  epidemic,  which  tended  towards  its  exhaustion 
and  decline,  but  there  is  also  the  important  fact  that  difficulties  arose  in 
opportunities  of  renewal  of  the  disease  by  fresh  invasions.  The  abandon- 
ment of  the  Mediterranean  as  the  centre  of  commerce  for  Europe,  the 
shutting  up  of  the  Levant  as  the  high  road  for  the  conveyance  of  the 
produce  of  the  East  to  the  West,  and  the  transfer  of  commercial  activity 
s.  3 


34  History  and  Dhtrihution  of  PlaffKe        [part  i 

to  Amsterdam  and  London,  whose  connections  with  the  Far  East  were 
by  sea  and  not  by  land,  and  consequently  the  avoidance  of  the  former 
intimate  connection  with  endemic  centres,  were  changes  which  came 
into  operation  in  the  early  part  of  the  17th  century;  and  it  appears 
that  it  is  in  these  great  changes  in  the  commercial  relations  of  Western 
Central  Europe  that  the  explanation  of  the  rapid  disappearance  of 
plague  from  Europe  is  to  be  sought,  once  the  influence  of  war  in 
Central  Europe  and  famine  in  France  was  over,  rather  than  in  any 
great  social  change  effected  at  that  period. 

Under  these  circumstances,  quarantine,  as  practised  in  the  Mediter- 
ranean ports,  became  easier  in  its  application  and  more  effective  in  its 
results.  Plague  continued  at  intervals  in  the  neighbourhood  of  the  new 
overland  route,  and  in  those  countries  with  which  Turkey  was  at  war, 
for  more  than  another  century,  but  it  spread  very  little  out  of  the  beaten 
track. 

During  the  18th  and  the  early  part  of  the  19th  century  plague 
Plague  in  the  continued  to  prevail  in  Turkey,  Asia  Minor,  Syria  and 
isth  century.  Egypt,  and  from  there  the  disease  occasionally  extended 
to  those  countries  immediately  bordering  on  their  territories  or  to  ports 
in  very  intimate  intercourse  with  them.  In  1709  it  was  in  Russia  and 
it  is  estimated  that  over  150,000  persons  died  in  the  epidemic.  In 
1719  it  prevailed  in  Transylvania,  Hungary  and  Poland,  and  again  in 
Hungary,  Moravia  and  Austria  from  1738-1744.  Its  extension  beyond 
the  countries  mentioned  was  rare.  Sometimes  the  spreading  of  the 
disease  was  connected  with  commerce  and  sometimes  with  war. 

The  plague  of  Marseilles  in  1720  was  imported  from  Tripoli  in  Syria 
by  a  merchant  vessel  which  had  lost  six  of  its  crew  on  the  voya.ge  from 
the  disease.  From  Marseilles  the  plague  spread  to  Toulon,  and  in  the 
two  towns  nearly  90,000  persons  died. 

The  plague  in  Messina  in  1743  was  brought  by  a  merchant  vessel 
from  the  Morea.  The  captain  put  in  at  Misselonghi  in  the  Gulf  of 
Lepanto  and  there  renewing  a  clean  bill  of  health  deceived  the  health 
authorities  as  regards  the  original  port  which  the  vessel  started  from. 
He  moreover  accounted  for  a  death  on  board  by  attributing  it  to  an 
accident  in  which  one  of  the  sailors  fell  overboard.  The  captain  died 
on  the  24th  March,  four  days  after  the  arrival  of  the  ship,  and  one  of 
the  sailors  three  days  after  the  captain.  The  landed  goods  and  the 
vessel  were  burnt  and  the  rest  of  the  crew  placed  in  the  Lazaretto. 
These  measures  allayed  all  alarm.  In  the  meantime  a  fisherman  had 
received  from  the  captain  some  infected  goods  and  had  taken  them 
home.     The  plague  first  appeared  in  this  quarter  of  the  town.     But  so 


CH.  i]  Plague  in  Moscoiv  35 

slow  was  its  progress  that  on  the  15th  of  May  a  thanksgiving  service 
was  held  for  deliverance  from  this  terrible  malady.  One  physician  per- 
sisted in  stating  that  a  number  of  his  patients  were  suffering  from 
plague,  but  his  announcement  was  so  unwelcome  that  he  narrowly 
escaped  with  his  life.  From  the  15th  to  the  31st  of  May  between  three 
and  four  hundred  people  perished,  and  yet  on  the  31st  of  May  at 
a  Council  held  at  the  Governor's  palace  twenty  three  of  the  physicians 
solemnly  declared  that  the  disease  was  not  the  plague.  Notwithstanding 
this  the  deaths  rose  early  in  June  to  one  hundred  a  day,  and  then  the 
Government  becoming  alarmed  issued  orders  for  the  necessary  regula- 
tions :  "  ^  A  panic  terror  seized  at  once  the  people  and  the  city  was  in 
a  manner  abandoned,  except  by  the  magistrates  of  the  health  and  senate, 
who  kept  firm  in  the  discharge  of  their  duty,  and  only  one  of  each 
magistracy  survived.  But  none  of  these  orders  were  executed,  the 
common  people  could  not  be  kept  under  any  government,  so  that  many 
who  had  shut  themselves  up  in  their  houses,  began  to  think  of  providing 
themselves  by  force  of  money  not  only  with  the  common  necessaries  for 
their  sustenance  as  flour,  rice,  oil,  etc.,  but  also  firearms  and  powder  to 
be  able  to  make  defence  against  the  fury  of  the  populace,  who  would 
have  assuredly  committed  violence  had  they  not  perished  so  very 
suddenly  by  the  distemper  which  swept  away  the  greater  part  in  a  few 
days.  The  principal  mortality  did  not  continue  above  20  days,  that  is 
from  the  12th  of  June  to  the  beginning  of  July." 

Cyprus  in  the  years  1759  and  1760  suffered  from  a  severe  epidemic 
of  plague,  Nicosia  losing  25,000  of  its  inhabitants.  The  disease  was  first 
introduced  by  infected  Turkish  sailors  shipwrecked  not  far  from  Limsol, 
and  later  by  merchant  vessels  from  Damietta.  It  lasted  two  years, 
spread  over  the  greater  part  of  the  island  and  destroyed  70,000  of  its 
inhabitants. 

The  plague  of  Moscow  in  1771,  on  the  other  hand,  was  the  result 
of  war.  It  occurred  when  Catherine  was  at  war  with  the  Turks, 
the  Russian  troops  becoming  infected  as  early  as  September  1769  by 
Turkish  prisoners  of  war.  The  infected  troops  returning  to  Jassy 
spread  plague  among  the  inhabitants  and  later  carried  it  to  Moscow, 
which  lost  over  60,000  of  its  population.  The  disease  was  unrecognised 
at  first  and  was  called  malignant  epidemic  fever,  not  an  uncommon 
mistake  in  the  early  days  of  a  plague  epidemic.  At  the  commence- 
ment its  progress  was  slow.  The  infection  was  introduced  in  October 
1770,  but  it  was  not  until  March  1771  that  the  disease  assumed 
1  A  Treatise  of  the  Plague,  p.  516.     By  Patrick  Russell,  M.D.,  F.R.S.,  1791. 

3—2 


36  Historij  and  .Distribution  of  Plague       [parti 

threatening  proportions  and  the  people  became  alarmed.  According 
to  Dr  Athanasius  Shafonski,  who  writes  an  account  of  the  epidemic  and 
is  quoted  by  Dr  F.  C.  Clemow',  there  were  in  April  778  deaths,  in  May 
878,  in  June  1099,  in  July  1708,  in  August  7268,  in  September  21,401, 
in  October  17,561,  in  November  5235,  and  in  December  805.  The 
plague  continued  throughout  1772,  and  it  was  not  until  December  that 
Moscow  was  officially  declared  to  be  free  from  plague.  On  its  rapid 
development  in  Moscow  it  invaded  the  provinces  of  the  south  and  west 
and  destroyed  300,000  of  the  inhabitants. 

At  the  close  of  the  18th  century  when  plague  was  affecting  the 

French  army  in  Egypt,  West  Barbary  suffered  severely 

West  from  plague.     It  is  not  known  how  the  disease  originated. 

ary.  Some  ascribed  it  to  infected  merchandise   imported   into 

Fas  from  the  East ;  others  attributed  it  to  the  locusts  which  had 
infested  West  Barbary  during  the  seven  preceding  years.  It  was 
a  most  destructive  and  wide-spread  epidemic  and  is  estimated  to  have 
destroyed  two-thirds  of  the  population  of  the  empire.  Morocco  lost 
50,000  of  its  inhabitants.  Fas  65,000,  Mogodor  4500,  and  Sa%  5000. 
Many  villages  had  nearly  the  whole  of  their  inhabitants  swept  away. 
Deabet,  a  village  near  Mogodor,  lost  100  persons  out  of  133  in  twenty 
days,  though  it  remained  free  for  over  a  month  from  disease  whilst 
Mogodor  was  suffering,  notwithstanding  daily  communication.  The 
naiTator  records  the  following:  "-Travelling  through  the  province  of 
Haba  shortly  after  the  plague  had  exhausted  itself  I  saw  many  unin- 
habited ruins,  which  I  had  before  witnessed  as  flourishing  villages. 
On  making  inquiry  concerning  the  population  of  the  dismal  remains 
I  was  informed  that  in  one  village  which  contained  600  inhabitants 
four  persons  only  had  escaped  the  ravage.  Other  villages  which  had 
contained  four  or  five  hundred  had  only  seven  or  eight  survivors  left 
to  relate  the  calamities  they  had  suffered.  Families  which  had  retired 
to  the  country  to  avoid  the  infection  on  returning  to  town  when  all 
infection  had  apparently  ceased  were  generally  attacked  and  died. 
A  singular  instance  of  this  kind  happened  at  Mogodor  where  after  the 
mortality  had  subsided  a  corps  of  troops  arrived  from  the  city  of 
Zerodant  in  the  province  of  Suse  where  the  plague  had  been  raging, 
and  had  subsided  ;  these  troops  after  remaining  three  days  at  Mogodor 

1  "  Plague  epidemics  in  Russia."  By  Frank  C.  Clemow,  M.D.,  Indian  Medical  Gazette, 
Sept.  and  Oct.  1898. 

^  An  account  of  Timbuctoo  and  Ilauxa  Territories  in  the  interior  of  Africa,  by  El  Hajee 
Abd.  Salam  Shabeeny  with  notes  critical  and  explanatory.  By  James  Grey  Jackson, 
Resident  for  upwards  of  16  years  in  South  and  West  Barbary  in  a  diplomatic  and  com- 
mercial capacity,  1820. 


CH.  i]  Contimied  Retrocession  of  Plcufue  37 

were  attacked  with  the  disease  and  it  raged  exclusively  among  them  for 
about  a  month,  during  which  it  carried  off  two-thirds  of  their  original 
number,  one  hundred  men ;  during  this  interval  the  other  inhabitants 
of  the  town  were  exempt  from  the  disorder,  though  these  troops  were 
not  confined  to  any  particular  quarter,  many  of  them  having  had  apart- 
ments in  the  houses  of  the  inhabitants  of  the  town."  This  epidemic  of 
plague  in  1799  in  West  Barbary  had  only  been  rivalled  in  violence  by 
the  pandemic  in  the  14th  century  when  two-thirds  of  the  population 
perished. 

As  plague  prevalence  lessened  the  origin  of  plague  epidemics  in 
healthy  localities  became  easier  to  trace  and  resolved  itself,  in  the  case 
of  Europe,  into  importation  of  the  infection  from  infected  localities. 
Recrudescences  in  the  same  locality  might  recur  year  after  year  for 
a  longer  or  shorter  period,  but  with  this  exception  plague  was  an  exotic 
which  could  seldom  maintain  itself  in  one  place  except  by  fresh  invasions 
brought  about  by  the  movement  of  troops  or  the  activity  of  commerce. 

In  the  early  part  of  the  19th  century  plague  still  lingered  in  Turkey, 
Plague  in  the  Asia  Minor,  Syria  and  Egypt.  In  1803  Constantinople 
I9tii  century.  j^g^  150,000  of  its  inhabitants  from  the  disease.  There 
was  a  lull  again  until  1812-13  when  the  same  city  lost  another 
100,000.  Only  twice  in  the  century  did  plague  extend  beyond  these 
limits,  once  in  1812-15  and  again  in  1828-29.  On  both  occasions 
it  spread  to  the  frontiers  of  Austria  and  of  Russia,  becoming  epidemic 
in  Odessa,  the  Crimea,  Wallachia,  Moldavia  and  Transylvania.  In  the 
former  years  it  reached  Malta  and  Noja. 

In  1829  it  was  epidemic  in  Greece  after  an  absence  of  a  century, 
having  been  imported  by  Egyptian  troops.  Finally  it  was  epidemic  in 
Constantinople  in  1831  and  again  in  1841  and  in  Egypt  in  1844.  Then 
as  in  the  West  at  the  end  of  the  17th,  so  in  the  East  towards  the  middle 
Disappear-  of  the  19th  century  a  repetition  of  the  phenomenon  which 
ance  of  has  been  more  than  once  noticed  in  the  history  of  plague 

Turkey  and  occurred.  In  the  course  of  five  years,  from  1839  to 
nuddi  ^°f*^^  1844,  plague  disappears  entirely  from  its  old  haunts  in 
the  19th  South-Eastern  Europe,  the  Levantine  countries  and  Egypt, 

century.  j^^  ^^^^  ^j^^  Russian  Government  and  in  1849  the  Austrian 

Government  sent  commissions  to  Egypt  to  enquire  as  to  the  disappear- 
ance of  plague  from  that'country.  Both  commissions  failed  to  discover 
a  single  case  of  plague. 

The  cessation  of  plague  in  the  Levantine  regions  in  the  middle  of 
the  19th  century  was  a  remarkable  phase  in  the  natural  history  of  the 
disease,  but  it  was  not  more  remarkable  than  that  which  occurred  in  the 


38  History  and  Disfrihnfion  of  Pfaf/ue        [part  i 

8th  century  and  which  was  followed  by  a  prolonged  period  of  quiescence. 

Measured  by  the  standard  of  great  epidemics  plague  has  been  since 

1844   quiescent    in    the    Levantine    regions    some    60   years,  but    that 

quiescence  is  short  compared  with  the  duration  of  the  former  lull. 

Notwithstanding  the  disappearance  of  plague  from  Turkey,  Eg}^t, 

Syria  and  Asia  Minor,  the  disease  exhibited  at  intervals 

descence  of        ^  leisurely  activity  in  Arabia,  Mesopotamia,  Persia  and  the 

plague  in  coast  of  Tripoli.     In  1853,  nine  years  after  the  disappear- 

Arabia   Meso-  .  . 

potamia,  ance  of  plague  in  Eg)'pt,  an  outbreak  of  the  disease  was 

Persia  and  heard  of  in  Assvr,  a  mountainous  district  of  Western  Arabia 
Benghazi.  -^    ' 

in  Northern  Yemen.     This  is  an  isolated  region  in  which 

epidemics  of  plague  are  known  to  have  occurred  in  1826,  in  1832  and 
in  1844,  since  which  time  there  have  been  almost  annual  recurrences. 
These  epidemics  are  limited  to  the  high  Assyr  plateau.  Probably 
endemicity  of  plague  in  this  plateau  is  even  of  more  ancient  date. 
According  to  Kremer  a  virulent  outbreak  of  plague  is  mentioned  in  this 
region  as  far  back  as  1157.  Since  1853  there  have  been  severe  out- 
breaks in  Assyr  in  1874,  1879,  1887,  and  1889.  In  1858  the  disease 
once  more  reappeared  at  Benghazi  on  the  coast  of  Tripoli  after  an 
absence  of  15  years,  and  again  in  1874.  The  events  preceding  the 
plague  in  Benghazi  were  three  or  four  years  of  unusual  drought  followed 
by  famine  and  an  epizootic  among  cattle.  It  was  at  a  time  of  the 
utmost  misery  that  plague  broke  out  in  an  Arab  camp.  Plague  was 
also  heard  of  as  prevailing  in  epidemic  form  in  1863  in  Persian  Kurdistan, 
and  further  south  in  the  same  district  in  1870,  1871,  the  villages  being 
situated  some  6000  to  7000  feet  above  the  level  of  the  sea.  Later 
investigations  indicate  that  this  highland  region  has  been,  like  Assyr, 
an  endemic  centre  of  plague  for  many  years.  Tholozan  counted  15 
epidemics  between  1865  and  1875. 

To  the  south  of  Kurdistan  in  Mesopotamia  in  the  plains  of  the 
Euphrates  and  Tigris  plague  is  recorded  as  having  been  prevalent  in 
one  district  in  1867,  in  another  in  1873-75,  in  a  third  including  Bagdad 
in  1873-75,  and  again  in  1880-81,  a  fourth  in  1884-85,  and  a  fifth 
in  1891-92.  Tholozan  considers  Mesopotamia  or  Irak  Arabi  to  be  a 
secondary  plague  centre,  being  of  opinion  that  the  plague  is  imported 
from  the  mountainous  districts  of  Turkish  and  Persian  Kurdistan 
along  the  Euphrates.  This  would  agree  with  what  is  known  of  the 
topographical  features  of  the  endemic  centres  in  India  and  China,  both 
of  which,  Kumaon  and  Garhwal  in  India  and  Yunnan  in  China,  are  at  a 
high  altitude.  To  the  east  of  Kurdistan  plague  appeared  in  Astrabad 
in   1876-77,  in   Resht  in   1877,  and  at   the   mouth    of  the   Volga  in 


CH.  i]  The  last  Outbreak  in  Europe  39 

1878-79.  Astrakhan  at  the  mouth  of  the  Volga  is  a  great  resort  at 
certain  seasons  of  the  year  for  Persian  fishermen,  so  that  diseases  pre- 
valent in  Persia  are  soon  apt  to  find  their  way  by  this  route  to  this 
part  of  Russia.  This  outbreak  in  the  province  of  Astrakhan,  being  the 
first  in  Europe  since  its  disappearance  from  Turkey  in  1841,  gave  rise 
to  much  alarm  and  particularly  so  on  account  of  its  destructive  character 
in  the  village  of  Vetlianka,  where  in  less  than  two  months  it  caused  350 
deaths  in  a  population  of  1700  inhabitants.  It  attacked  six  other  small 
and  adjacent  communities  on  the  banks  of  the  Volga  and  destroyed 
Plague  in  the  altogether  about  420  persons.  The  disease  began  early  in 
Province  of  October  and  at  the  commencement  manifested  itself  in  a 
mild  form.  The  patients  suffered  from  fever,  slight  but 
debilitating.  They  had  abscesses  of  the  lymphatic  glands,  either  in  the 
groin  or  in  the  armpit,  which  suppurated  freely,  and  the  duration  of  the 
sickness  was  from  10  to  20  days.  The  disease  gradually  became  more 
virulent,  and  at  the  height  of  the  epidemic  from  December  the  9th  to 
the  21st  the  mortality  reached  100  "/o  of  those  attacked^ 

The  early  stages  of  this  epidemic  with  its  mild  form  of  plague  were 
similar  to  a  bubonic  or  glandular  malady  which  had  prevailed  the  year 
before  in  the  city  of  Astrakhan  and  its  suburbs,  where  some  200  of  the 
inhabitants  were  affected  and  only  one  died.  The  outbreak  in  Vetlianka 
was  the  last  appearance  of  plague  in  Europe  for  17  years-. 

1  "  On  the  progress  of  Levantine  plague  in  1878-79,"  by  Mr  Netten  Kadcliffe.  Medical 
Supplement  to  the  Nintli  Annual  Report  of  the  Local  Government  Board,  1879-80. 

-  Though  the  plague  had  disappeared  from  Europe  Dr  Bruce  Low  [Twenty -eighth 
Anmial  Report  of  the  Local  Gorermnent  Board,  1898-99.  Medical  Supplement.  "On  the 
diffusion  of  bubonic  plague  from  1879  to  1898,"  by  Dr  Bruce  Low)  in  a  brief  summary 
shows  that  from  1879  to  189()  not  a  single  year  passed  without  the  development  of  plague 
in  at  least  one  country,  and  in  later  years  the  disease  was  present  in  several  countries  at 
one  and  the  same  time. 

"In  1880  plague  was  reported  to  be  present  in  Mesopotamia. 

,,  1881  it  was  present  in  Mesopotamia,  Persia  and  China. 

,,  1882  in  Persia  and  China. 

„  1883  in  China. 

,,  1884  in  China  and  in  India  (as  "  Mahamari  "). 

,,  1885  in  Persia. 

,,  1886  in  India  (as  "Mahamari")  ^    Mahamari     in    the 

,,  1887  in  India  (as  "Mahamari")   J-  districts  of  Kumaon 

,,  1888  in  India  (as  "Mahamari")  J    and  Garhwal. 

,,  1889  in  Arabia,  Persia  and  China. 

,,  1890  in  Arabia,  Persia  and  China. 

,,  1891  in  Arabia,  China  and  India  (as  "  Mahamari  "). 

,,  1892  in  Mesopotamia,  Persia,  China,  Russia  and  ?  Tripoli. 

,,  1893  in  Arabia,  China,  Russia  and  India  (as  "  Mahamari  "). 

,,  1894  in  Arabia,  China  and  India  (as  "Mahamari"). 

,,  1895  in  Arabia  and  China. 

,,  1896  in  Arabia,  Asia  Minor,  China,  .Tapan,  Russia  and  India." 


CHAPTER  II. 

PLAGUE   IN   INDIA. 

The  English  established  factories  at  Surat,  Ahmedabad,  Bombay 
Plague  In  and  Agra,  at  the  beginning  of  the  17th  century,  and  until 

India.  ^j^g^^  time  and  even  later  the  history  of  plague  in  India 

is  veiled  in  obscurity.  That  plague  did  prevail  in  India  in  or  before 
the  11th  or  12th  century  is  certain,  for  in  some  of  the  Puranas  which 
are  at  least  800  years  old  there  are  references  to  the  disease  and 
instructions  to  the  Hindus  as  to  the  precautions  to  be  taken  in  the 
event  of  its  appearance.  One  of  these  is  that  wheneve'K  a  mortality 
among  the  rats  of  a  house  is  observed  the  inhabitant's'  are  to  leave. 

It  has  already  been  stated  that  according  to  the  Arabian  chronicles 
India  was  severely  visited  by  plague  in  1031,  and  that  this  epidemic 
spread  to  the  vicinity  of  Constantinople.  It  has  also"  been  stated  that 
Russian  authors  ascribed  the  origin  of  the  great  pandemic  of  the 
14th  century  to  the  advance  of  an  epidemic  from  India.  There  is 
evidence  of  extensive  pestilences  in  India  in  the  14th,  loth  and 
16th  centuries.  References  to  these  are  to  be  found  in  the  history 
of  the  Mahommedan  wars.  Doctors  George  and  John  Thomson^  in 
their  treatise  on  plague  mention  the  years  1345,  1399,  1438,  1574  and 
1597  as  plague  years  in  India.  Nathan^  taking  his  information  from 
the  Bombay  Gazetteer,  in  the  article  on  Ahmedabad,  mentions  two  re- 
ferences which  may  point  to  the  existence  of  plague  in  the  west  of  India 
in  the  14th  and  15th  centuries.  The  first  is  from  Ibn  Batuta,  who 
notices  that  Muhammad  Tughlik's  army  in  Ma'bar  (1325-51)  mostly 
perished  of  pestilence,  and  that  at  the  end  of  the  century  (1399),  after 
Timur  left,  the  districts  through  which  he  passed  were  visited  by  pesti- 
lence.    The  second  relates  to  the  year  1443  when  in  Malwa  the  plague 

^  A    Treatise   on  Plague.      By    Major    (ieorge    S.    Thomson,    I.M.S.,    and    Dr   John 
Thomson.     1901. 

2  The  Plague  in  India,  1896,  1897.     R.  Nathan. 


CH.  ii]  Plague  in  the  Seventeenth  Ceiituvji  41 

caused  such  loss  of  life  in  Sultan  Ahmad  I.'s  army  that,  leaving  many 
of  the  dead  unburied,  he  returned  to  Gujarat. 

The  connection  established  between  Northern  India  and  the  endemic 
areas  of  plague  in  Central  Asia,  Persia,  and  Irak  by  the  Mongols  would 
facilitate  the  spread  of  plague  into  India  in  these  early  periods. 

In  the  first  decade  of  the   I7th  century  plague  appears  to  have 

broken  out  in  the  Punjaub  and  spread  over  different  parts 

early  part  of      <^f  India,  lasting  about  eight  years.     Its  commencement 

the  17th  seems  to  have  been  connected  with  disease  in  Kandahar 

century. 

in  which  the  land  was  overrun  with  mice^ 

The  Emperor  Jehangir  writing  of  this  epidemic  in  his  memoirs  says, 

"  -In  this  year  (1615  A.D.),  or  rather  in  the  tenth  year  of  my  reign,  plague 

(waba)  broke  out  in  many  parts  of  Hindustan.     It  first  appeared  in  the 

Plague  in  the     districts  of  the  Punjaub  and   gradually  came  to  Lahore. 

Punjaub.  j^  destroyed  the  lives  of  many  Mahommedans  and  Hindus. 

It  spread  through  Sirhind  and  the  Doab  to  Delhi  and  its  dependent 

districts,  and  reduced  them  and  the  villages  to  a  miserable  condition. 

Now  it  has  wholly  subsided."     Nawab  Mu'tamad  Khan  referring  to  the 

same  event  in  the  Ikbdl-ndma'-'  mentions   its  precedence  by  a  mouse 

mortality.     "  When   it   was   about   to  break   out   a   mouse  would   rush 

out   of  its   hole   as  if  mad,  and   striking  itself  against   the   door  and 

the  walls  of  the  house,  would  expire.     If  immediately  after  this  signal 

the  occupants  left  the  house  and  went  away  to  the  jungle,  their  lives 

were  saved ;  if  otherwise  the  inhabitants  of  the  whole  village  would  be 

swept  away  by  the  hand  of  death."     Mu'tamad  Khan  also  adds  more 

information  c<jncerning  the  epidemic  than  that  found  in  the  memoirs  of 

the  Emperor  Jehangir.     Thus,  "  If  any  person  touches  the  dead,  or  even 

the  clothes  of  the  dead  man,  he  also  could  not  survive  the  fatal  contact. 

The  effect  of  the  epidemic  was  comparatively  more  severe  upon  the 

Hindus.     In  Lahore  its  ravages  were  so  great  that  in  one  house  ten  or 

even  twenty  persons  would  die,  and  their  surviving  neighbours  annoyed 

by  the  stench  would  be  compelled  to  desert  their  habitations.     Houses 

full  of  the  dead  were  left  locked,  and  no  person  dared  to  go  near  them 

through  fear  of  his  life.     It  was  also  very  severe  in  Kashmir  where  its 

effects  were  so  great  that  (as  an  instance)  a  darwesh  who  had  performed 

the  last  sad  offices  of  washing  the  corpse  of  a  friend,  the  very  next  day 

1   Bornbmj  Gazetteer,  Vol.  iv.  c.  xii.  p.  218. 

^  "  The  History  of  India  as  told  by  its  own  Historians."  The  jwsthumotis  papers  of  the 
late  Sir  H.  M.  Eliot,  K.C.B.  Edited  and  continued  by  Professor  John  Dowson,  Vol.  vi. 
p.  316.     1875. 

»  Ibid.  p.  406. 


42  HUtoi'ji  (iml  DUtrlhntion  of  Pkufne        [part  i 

shared  the  same  fate.  A  cow  which  had  fed  upon  the  grass  on  which 
the  body  of  the  man  was  washed  also  died.  The  dogs  also  which  ate 
the  flesh  of  the  cow  fell  dead  upon  the  spot.  In  Hindustan  no  place 
was  free  from  this  visitation  which  continued  to  devastate  the  country 
for  a  space  of  eight  years." 

The  following  note  kindly  supplied  to  the  author  by  Mr  W.  Foster 
of  the  India  Office  refers  to  the  plague  epidemic  in  Ahmedabad  in  1617 
and  1618. 

"'The  city  Amadawar-  (at  our  being  there  with  the  King^)  was 
Plague  in  visited  with  this  Pestilence  in  the  month  of  May,  and  our 

Ahmedabad.  f;xmily  was  not  exempted  from  that  most  uncomfortable 
visitation ;  for  within  the  space  of  nine  dayes  seven  persons  that  were 
English  of  our  family  were  taken  away  by  it :  and  none  of  those  that 
dyed  laid  sick  above  twenty  houres,  and  the  major  part  well  and  sick 
and  dead  in  twelve  houres,  as  our  Surgeon  (who  was  there  all  the 
Physician  we  had)  and  he  le(^  the  way,  falling  sick  at  mid-day  and  the 
following  mid-night  dead.  And»  there  w^as  three  more  that  followed  him, 
one  immediately  after  the  other,  who  made  as  much  hast  to  the  grave  as 

he  had  done All  those  that  dyed  in  our  family  of  this  pestilence  had 

their  bodyes  set  all  on  fire  by  it,  as  soon  as  they  were  first  visited,  and 
when  they  were  dying  or  dead,  broad  spots  of  a  black  and  blew  colour 
appeared  on  their  brests ;  and  their  flesh  was  made  so  extreme  hot  by 
their  most  high  distemper  that  we  who  survived  could  scarce  endure  to 

keep  our  hands  upon  it.    It  was  a  most  sad  time,  a  fiery  trial  indeed 

All  our  family  (my  Lord  Ambassadour*  only  excepted)  were  visited  with 
this  sickness  and  we  all,  who  through  God's  help  and  goodness  outlived 
it,  had  many  great  blisters,  fild  with  a  thick  yellow  watry  substance  that 
arose  upon  many  Parts  of  our  bodyes,  which,  when  they  brake,  did  even 
burn  and  corrode  our  skins,  as  it  ran  down  upon  them  !" 

Information  is  also  obtained  from  other  sources  of  this  epidemic  in 
Hindustan.  In  the  account  of  the  Embassy  of  Sir  Thomas  Roe  to  the 
Court  of  the  Great  Mogul  1615-19  it  is  stated^:  "I  received  news  of 
a  great  plauge  at  Agra  so  that  I  judgd  it  dangerous  to  send  up 
the  goodes  into  an  infected  place. from  whence  no  Comodytye  could 
be  suffered  to  passe." 

^  A  Voijaf/e  to  East  India.     By  the  l\cv.  Edward  Teft'ry,  Chai)lain  to  Sir  Thomas  Eoe, 
published  1655,  p.  242. 

2  The  old  way  of  spelling  Ahmedabad. 

s  Dec.  1617  to  Sept.  1618.  "  Sir  Thomas  Roe. 

5  Page  307. 


CH.  ii]  Plaqve  in  the  Seventeenth   Century  43 

Joseph  Salbank  in  one  of  his  letters^  mentions  in  1(310  that  plague 
Plague  In  ^^^  existed  at  Agra  for  three  months,  and  that  there  was 

As^*-  sometimes  a  daily  mortality  of  1000  persons.     Lahore  is 

also  mentioned  as  being  affected,  in  another  letter.  The  plague  con- 
tinued in  Agra  for  at  least  four  years.  The  plague-  is  referred  to  as 
increasing  in  Agra  early  in  1619. 

The  Emperor  Jehangir's  autobiography''  contains  the  following 
account  of  the  plague  at  Agra:  "At  this  time  those  who  were  loyal 
represented  that  the  disease  of  the  plague  (taun)  was  prevalent  in  the 
city  of  Agra,  so  that  in  a  day  100  people  ^  more  or  less,  were  dying  of  it. 
Under  the  armpits,  or  in  the  groin,  or  below  the  throat  a  lump  comes 
and  they  die.  This  is  the  third  year  that  it  has  raged  in  the  cold  weather 
and  disappeared  in  the  commencement  of  the  hot  season.  It  is  a 
strange  thing  that  in  these  three  years  the  infection  has  spread  to  all 
the  towns  and  villages  in  the  neighbourhood  of  Agra,  and  there  has 
been  no  trace  of  it  in  Fattehpur  (Sikri)  and  as  far  as  for  two  and  a  half 
koss  from  Amanabad  to  Fattehpur.  The  people  of  that  place  have 
forsaken  their  own  homes  and  gone  to  other  villages." 

The  following  extract  from  the  Emperor's  journal  relates  to  an 
occurrence  which  is  particularly  interesting  as  an  observation  on  the 
intimate  relationship  between  rat  plague,  cat  plague  and  human  plague. 
To-day  similar  instances  might  readily  be  quoted  in  which  the  plague 
mouse  or  rat  in  a  house  infects  the  cat  and  afterwards  plague  breaks  out 
in  the  house.  "  The  daughter  of  the  deceased  Asaf  Khan  who  is  in  the 
house  of  Khan-i-Azam,  told  me  a  strange  and  wonderful  tale.  I  made 
particular  enquiries  into  its  truth  and  write  it  on  account  of  its- 
strangeness.  She  said  that  one  day  in  the  court-yard  of  her  house 
she  saw  a  mouse  falling  and  rising  in  a  distracted  manner.  It  was 
running  about  in  every  direction  after  the  manner  of  drunkards,  and 
did  not  know  where  to  go.  She  said  to  one  of  her  female  slaves, 
'  Take  it  by  the  tail  and  throw  it  before  the  cat.'  The  cat,  delighted, 
jumped  up  from  its  place  and  seized  it  in  its  mouth,  but  immediately 
dropped  it  and  showed  aversion  to  it.  By  degrees  an  expression  of 
grief  and  pain  showed  itself  in  its  face.     The  next  day  it  was  nearly 

^  Letters  received  by  the  East  India  Company,  Vol.  vi.  p.  198.  Edited  by  William 
Foster,  B.A.,  1902. 

'^  Letters  from  Surat  to  East  India  Company,  March  12,  1619. 

=*  "Plague  an  old  Indian  disease."  By  Alex.  Eogers.  The  Indian  Magazine  and 
Review,  January,  1898. 

■•  There  is  a  ^reat  different-e  between  the  estimates  of  the  number  of  daily  deaths  {,'iven 
by  Salbank  and  the  Emperor  Jehangir.     The  latter  is  more  likely  to  be  correct. 


44  History  aiul  Disfrihnfwii  of  Plafpie        [part  i 

dead,  when  it  entered  into  her  mind  to  give  it  a  little  treacle.     When 

its  mouth  was  open  its  palate  and  tongue  appeared  nearly  black.     It 

passed  three  days  in  a  state  of  misery,  and  on  the  fourth  day  came  to 

its  senses.    After  this  the  grain  of  the  plague  (danah  or  bubo)  appeared 

in  one  of  the  female  slaves  and  from  excess  of  temperature  and  increase 

of  pain  she  had  no  rest.     Her  colour  became  changed ;  it  was  yellowish 

inclining  to  black  and  the  fever  was  high.     The  next  day  she  was  free 

of  fever  and  died.     Seven  or  eight  people  in  the  house  died  in  the  same 

way,  and  some  were  ill.     On  the  day  I  went  to  the  garden  from  that 

halting  place,  those  who  were  ill  in  the  garden  died  and  in  that  place 

the  bubo  did  not  appear  again.     Briefly  in  the  space  of  eight  or  nine 

days  17  people  became  travellers  on  the  road  to  annihilation.     She  also 

said  :  '  Those  on  whom  the  boil  appeared,  if  they  asked  another  person 

for  water  to  drink  or  to  bathe  in,  these  also  caught  the  infection  and  at 

last  it  came  to  such  a  pass  that  through  extensive  suspicion  no  one 

would  pass  near  them '." 

Plague  is  again  recorded  as  prevalent  in  India  from  1684  to  1702. 

It  attacked  Surat  in  1684  and  Bombay  in  1689.     Surat 
Plague  at  the  .  "         .       . 

end  of  tue  was  at  that  time  a  town  of  greater  commercial  importance 

iTth  century.  ^]-^.^j^  Bombay.  It  possessed  all  the  unwholesome  condi- 
tions which  have  been  observed  to  favour  the  prevalence  of  virulence  of 
plague.  Crowded  and  unclean,  the  streets  were  narrow  and  in  places 
covered  with  excrement  of  man  and  beast.  Fryer,  who  visited  Surat 
some  time  before  the  outbreak,  wonders  that- a  city  whose  people  make 
the  streets  a  dung-hill  should  never  have  been  visited  by  the  plague. 
The  disease  when  it  was  imported  in  1684  continued  for  six  years 
without  interruption,  varying  in  intensity  at  different  seasons  of  the 
year.  Subsiding  during  the  rainy  season,  viz.  from  June  to  September, 
the  epidemic  broke  out  with  fresh  fierceness  in  October  and,  again 
abating  the  greater  part  of  the  cold  and  hot  seasons,  raged  with  renewed 
fury  towards  the  end  of  May. 

In  1684  the  disease  was  in  the  army  of  the  Emperor  Aurangzebe. 
The  following  details  of  the  prevalence  of  plague  about  this  time 
collected  from  different  records  are  given  by  Sir  James  Campbell  in  the 
fourth  volume  of  the  Bombay  Gazetteer. 

"*This  outbreak,  apparently  the  true  plague  taun  and  waba,  raged 

for  several  years  over  a  great  part  of  western  India.     At  Ahmedabad, 

where  it  lasted  for  seven  or  eight  years,  its  visible  marks  were  swellings 

as  big  as  a  grape  or  banana  behind  the  ears,  under  the  arms  and  in  the 

1  Gemelli  Careri  in  ChurchilVa  VoyafjeA,  iv.  p.  191. 


CH.  ii]  Plague  in  the  Nineteenth  Century  45 

groin,  and  redness  round  the  pupils  of  the  eyes.  In  1689  it  broke  out 
with  great  violence  at  Bijapur^  All  attacked  with  it  gave  up  hope ! 
It  had  been  in  the  Deccan  for  several  years.  Near  Goa  in  1684  it 
attacked  Sultan  Mosam's  army  and  carried  off  500  men  a  day^;  raged  in 
Surat  for  six  years  (1684-90)^  reduced  (1690)  the  Bombay  garrison 
to  35  soldiers^;  was  so  violent  that  it  not  only  took  away  all  means  of" 
preparing  a  good  end,  but  in  a  few  hours  in  Surat,  Daman  and  Thana 
carried  off  whole  cityfuls  of  people ^.  and  at  Tatha  in  Sind  (1696)  killed 
80,000  souls **.  In  Surat  Europeans  were  observed  to  enjoy  a  remarkable' 
immunity,  but  when  Bombay  was  attacked  in  1690  they  suffered  as- 
much  if  not  more  than  the  natives,  for  it  is  recorded  that  of  800 
Europeans  only  50  were  left,  of  whom  six  were  civilians,  six  commissioned 
officers,  and  not  quite  40  English  soldiers.  Bombay,  which  was  one 
of  the  pleasantest  places  in  India,  was  brought  to  be  one  of  the  most 
dismal  deserts." 

After  the  epidemic  in  the  l7th  century  plague  seems  to  have 
Plague  in  the  disappeared  from  India  as  completely  and  as  rapidly  as  it 
19th  century,  ^jj^j  fi-om  Western  Europe,  for  it  is  not  until  110  years 
later  at  the  beginning  of  the  19th  century  that  a  small  part  of  Cutch, 
Kdthidwar,  Gujarat  and  Sindh  were  again  affected  with  the  disease, 
which  continued  from  1812  to  1821.  It  was  at  the  close  of  a  famine 
that  plague  appeared  in  Cutch.  "''The  famine  of  1811  and  1812  was, 
at  the  close  of  1812,  followed  in  Cutch  by  an  outbreak  of  pestilence  so 
deadly  that  it  was  said  to  have  destroyed  half  the  ryots  in  the  country. 
At  the  same  time., a  'contagion  raged  at  Ahmedabad  with  a  fury  that 
can  scarcely  be  believed.'  Every  house  sickened,  whole  families  were 
carried  off  and  many  a  funeral  party  coming  back  to  the  house  of 
mourning  found  that,  in  their  absence,  another  member  of  the  family 
had  sickened  and  died.  So  thinned  were  some  castes  that  their  women 
had  to  help  to  carry  the  dead.  All  the  fuel  was  burned,  and  though 
houses  were  pulled  down  to  supply  logs  many  bodies  had  to  be  left 
half  consumed.  Half  of  the  people  of  Ahmedabad,  perhaps  about 
50,000  souls,  are  said  to  have  perished.  In  Ahmedabad  Musalmans 
and  Hindus  suffered  alike.  But  in  other  parts  it  was  noticed  that 
among  Musalmans  the  disease  was  less  fatal.  Of  the  symptoms  of 
this  sickness  no  details  are  recorded.  But  there  seems  every  reason  to 
suppose   th;'^   it  was   the  same  disease,  that  lulling  for   two  years,  in 

1  Muntakii  ^      I  Luhab  :  Elliot,  vii.  p.  337.  -  Orme's  Hixt.  Frag.  p.  142. 

•'  Ovington'P    'yyafie  to  Surat,  p.  347.  ■*  Bi'uce's  Annals,  in.  p.  !f4. 

'  Churchill,  ix>  p.  191.  ®  Hamilton's  New  Account,  i.  p.  123. 

^  Bombay  Gazetteer,  Vol.  iv.  p.  220. 


46  History  (ind  Distribution  of  Plague        [part  i 

May  1815,  after  one  of  the  heaviest  rainfalls  on  record,  broke  out 
afresh  with  deadly  force  at  Kantakot  in  east  Cutch.  In  cases  of  this 
disease  slight  fever  was  followed  by  great  weakness  and  weariness, 
and  then  swellings  came  in  the  groin  and  armpits,  suppurating 
in  some  cases  and  in  others  remaining  hard  lumps.  Few  stricken 
with  the  disease  recovered.     Most  died  between   the  third  and  ninth 

day It  seemed  to  attack  most  fiercely  the  sluggish  and  vegetable 

eaters;  Rajputs  escaped  where  Brahmans  and  Vainos  rotted  otf;  oil 
makers  were  believed  to  be  safe.  From  Kantakot  it  spread  to  other 
parts  of  Vagar,  causing  much  loss  of  life  in  the  early  months  (jf  1816. 
In  May  1816  it  crossed  to  Morvi  in  Kathi;iwar."  The  plague  in 
Kathiawar  was  observed  by  Dr  Gilder  and  Dr  Whyte,  both  of  whom 
reported  to  the  Government  on  the  epidemic.  Dr  Gilder  in  describing 
the  symptoms,  refers  to  the  two  forms  of  plague  observed,  the  knotty 
disease  and  the  expectorating  disease,  obviously  the  bubonic  and 
pneumonic  forms.  '  He  also  observed  that  the  epidemic  confined  itself 
principally  to  such  of  the  native  population  as  subsisted  entirely  on 
vegetable  diet,  namely,  Brahmins,  Soonars,  Dhurzees  and  Khoomtees ; 
those  using  animal  food  with  but  few  exceptions  generally  escaped.  It 
is  deserving  of  notice  that  this  epidemic  occurred  at  a  time  when  plague 
became  widely  diffused  in  the  Levant,  spreading  to  the  Lower  Danube, 
Asia  Minor,  Armenia,  and  Northern  Africa,  and  lasting  nearly  20  years. 
In  the  epidemic  of  1812-13,  100,000  persons  died  of  plague  in 
Constantinople. 

Nothing  more  is  heard  of  the  disease  on  the  western  side  of  India 
until  1836  when  the  Pali  plague  broke  out  in  Marwar  in  Raj pu tana, 
and  lasted  until  1838\  It  is  estimated  that  100,000  Marwaries  perished. 
The  Pali  plague  was  preceded  by  a  great  mortality  among  cattle  not 
only  through  Marwar  but  in  Mullani  and  the  desert  country  to  the 
west,  occasioned  by  a  complaint  said  to  be  different  from  the  epizootics 
usually  observed.  In  Pali  itself  from  November  1836  to  October  1837 
the  disease  was  mild  and  the  deaths  were  comparatively  few,  but  later 
it  acquired  a  more  virulent  form  and  became  more  prevalent  and  fatal. 
The  inhabitants  fied  from  the  town.  At  Taiwali  rats  died  just  before 
the  outbreak  of  plague  in  that  place.  Dr  Forbes  mentions  that 
Mr  White  reports  that  "  this  death  of  the  animal  attended  or  preceded 
the  disease  in  every  town  that  was  attacked  in  MarNv."^^-  so  that  the 
inhabitants  of  any  house  instantly  quitted  it  on  seeinjp'a  dead  rat." 

^   Thesis  on  the  Nature  and  History  of  Plague  as  observed  i)i  the  Nortn-West  Provinces  of 
India.     1840.     Dr  Forbes. 


CH.  ii]  Endemic  Centres  in  India  47 

The  epidemic,  which  was  limited  in  its  nature,  also  corresponded  in 
time  with  a  fresh  and  comparatively  limited  activity  in  the  Levant, 
which  affected  the  Turkish  dominions  in  Europe  and  Asia  as  well  as 
in  Egypt,  and  it  is  to  be  observed  that  the  disappearance  of  plague  in 
Rajputana  coincided  with  its  decline  and  ultimate  disappearance  in 
the  Levant.  Dr  Forbes  remarks  that  "for  some  years  prior  to  1832 
])lague  had  been  steadily  advancing  from  Asia  Minor  through  Mesopo- 
tamia, Irak,  round  the  head  of  the  Persian  Gulf  and  along  the  Persian 
coast,  desolating  the  cities  Dujarbehr,  Mosul,  Bagdad,  Busrah,  and 
Abusbeher,  at  which  place  it  ceased  or  was  withdrawn  from  European 
observation."  Pali'  is  the  chief  mart  of  Western  Rajputana  and  placed 
at  the  intersection  of  the  great  commercial  roads  from  Mandavi  in  Cutch 
to  the  Northern  States,  and  from  Malwa  to  Bahdwalpur  in  Sindh.  It  is 
in  a  centre  like  this  that  the  disease  being  brought  by  the  merchants 
would  once  more  come  under  observation. 

Apart  from  the  foregoing  epidemics  which  have  at  long  intervals 

prevailed  in  India  there  is  a  centre  of  plague  at  Garhwal 

ofGarhwai         ^^^^    Kumaon,    two    adjoining    districts    situated    on    the 

and  Kumaon       southern    slopes    of    the    Himalayas.      Here    plague    was 
endemic  ,^..  ,.  .. 

centres  of  discovered  to  exist  m  1823.     There  is  no  information  as 

plague  in  ^^  ^^^  j^j^g  ^j^|g  centre  of  plague  existed  previous  to  its 

recognition.  It  is  possible  that  the  plague  in  Kumaon  in 
1823  was  only  a  part  of  that  which  prevailed  in  Western  India  from  1812 
to  1821,  or  that  it  was  introduced  even  earlier  and  became  established 
during  the  plagues  of  the  14th,  15th,  or  17th  centuries.  Whatever 
may  be  the  date  of  its  origin,  there  can  be  little  doubt  that  Kumaon  is 
now  an  endemic  centre,  plague  having  occurred  in  limited  outbreaks 
even  as  recently  as  1897.  The  last  outbreak  before  plague  appeared  in 
Bombay  in  1896  was  in  July  and  September  of  1893,  and  occurred  in 
a  valley  some  6000  feet  high.  Fortunately  this  centre  is  comparatively 
an  inactive  one  as  regards  its  powers  of  diffusion,  which  is  in  favour 
of  its  being  a  branch  of  the  parent  stock  in  the  Levant,  which  has 
lost  not  only  its  powers  of  diffusion  but  also  the  power  of  retaining  its 
hold  on  countries  in  which  it  had  prevailed  for  centuries.  An  epidemic 
in  Hansi,  in  the  province  of  Delhi,  in  1828-29,  and  another  in  Rohilcund, 
around  Bareilly,  in  1836-38,  i)robably  owed  their  origin  to  Kumaon. 
'  Imperial  Gazetteer  of  India,  Vol.  xi.  p.  1. 


CHAPTER   III. 

THE   PRESENT   PANDEMIC. 

The  centre  of  interest  now  passes  from  Europe,  the  Levant  and  India 

The  present        ^'^  *^®  province  of  Yunnan  in  China  from  which  the  present 

pandemic  pandemic  originated.     The  acquisition   of  Hongkong  by 

in  Yunnan.         the  Briti.sh  in  1841  and  the  subsequent  opening  of  the 

one  of  the  treaty  ports  to  commerce  in  1860  were  the  first  incidents 

Western  .  i         i  •  i 

Provinces  in  the  process  of  breaking  down  that  exclusiveness  by 

of  China.  which   China   had  isolated  herself  from   the  intrusion  of 

foreigners.  Since  then  many  missionaries,  explorers  and  merchants 
have  penetrated  into  the  interior  of  China  which  until  their  visit  was 
for  Europeans  a  terra  incognita. 

They  have  given  accounts  of  their  experiences,  with  the  result  that, 
though  the  interior  of  China  as  a  whole  and  its  internal  affairs  are  still 
veiled  from  foreigners,  yet  much  more  is  known  concerning  important 
events  occurring  there  than  ever  before.  A  favourite  field  for  explora- 
tion was  Yunnan,  because  of  its  proximity  to  Burma,  Siam,  and  French 
Annam,  its  reputed  richness  in  minerals,  and  the  possibility  of  its 
becoming  a  highway  to  Western  and  Central  China.  The  sixties  and 
seventies  of  the  19th  century  were  remarkable  for  the  number  of 
intrepid  travellers  who  traversed  Yunnan  and  other  parts  of  China. 
Lagree,  Gamier,  Cooper,  Sprye,  Sladen,  Dupuis,  Rocher,  Richth, 
Margary,  Grosvenor,  Baker,  Gill,  and  later  Colquhoun  and  Bourne,  all 
distinguished  themselves  as  modem  pioneers. 

It  was  during  one  of  these  explorations  that  M.  Rocher  in  1871, 
i.e.  over  thirty  years  ago,  came  across  plague  in  the  province 
graphical  ^^  Yunnan.     This  province  is  situated  at  the  eastern  con- 

description  fines  of  Burma  and  Thibet,  has  Tonking  on  the  south,  the 
of  Yunnan.  .  . 

province  of  Sechuan  on  the  north,  and  the  provmces  of 

Kweichow  and  Kwangsi  on  the  east.  It  is  very  mountainous,  with  high 
and  fertile  plateaux,  which  ri.se  towards  the  central  portion  of  the  province 


CH.  Ill]  The  Promnce  of  Yunnan  49 

to  between  6000  and  7000  feet.  Talifu  and  Yunnanfn,  two  of  the  chief 
cities,  are  situated  on  the  shores  of  inland  lakes  and  on  plateaux,  respec- 
tively 6400  and  6900  feet  in  height. 

The  province  of  Yunnan,  isolated  by  its  position  and  its  physical 
features,  has  only  a  limited  intercourse  with  its  neighbours  and  with 
the  treaty  ports.  There  are  trade  routes  connecting  Talifu  and  Yun- 
nanfu  with  Burma,  Thibet,  and  the  province  of  Sechuan,  but  the 
mountainous  character  of  the  country  which  has  to  be  traversed,  and 
the  cost  and  difficulties  of  transport,  which  has  to  be  effected  by  pack 
animals,  cause  them  to  be  little  used.  Caravans  from  Thibet  pass 
Li  Chiangfu  on  their  way  to  Ssumao  for  tea. 

The  trend  of  intercourse  and  trade,  so  far  as  it  is  developed,  is 
Trade  routes  towards  Tonking  and  the  provinces  of  Kweichow,  Kwangsi, 
from  Yunnan.  .^j^^|  Kwantung.  Following  the  course  of  the  Red  River  in 
Tonking  and  the  West  River  in  Kwangsi  and  Kwantung,  the  journey 
can  be  undertaken  in  boats  for  at  least  some  part  of  the  way.  Both  the 
Red  River  and  West  River  rise  within  the  boundary  of  Yunnan,  and 
form  more  or  less  natural  trade  outlets  for  the  province.  The  Red  River 
is  navigable  from  Manhao  in  Yunnan,  and  passes  through  Tonking  to 
Haiphong  in  the  gulf  of  Tonking.  This  route,  notwithstanding  its 
advantages,  has  not  been  a  favourite.  The  West  River  is  navigable 
from  Pose,  a  small  town  situated  on  the  borders  of  Yunnan  and  Kwangsi, 
away  down  to  Nanningfu,  Wuchowfu,  and  Canton.  Even  this  route  has 
been  seldom  used  further  east  than  Nanningfu.  Almost  invariably, 
until  recent  years,  Yunnan  goods,  brought  down  the  West  River  as  far 
as  Nanningfu,  have,  at  that  point,  been  taken  from  the  boats  and  carried 
across  country  on  pack  animals  to  Pakhoi  and  more  recently  to  Muiluk. 
Similarly,  goods  intended  for  Yunnan  have  entered  Pakhoi,  been  con- 
veyed overland  to  Nanningfu,  been  there  transferred  to  boats,  taken  up 
the  river  to  Pose,  and  then  overland  again  to  the  towns  of  Yunnan. 

There  is  yet  another  trade  route  from  Yunnan  through  the  Kwangsi 
province.  It  is  more  northerly  than  that  by  Pose,  Nanningfu,  and  the 
West  River,  which  it,  however,  joins  before  this  waterway  enters  the 
province  of  Kwantung.  The  route  is  overland,  and  in  an  easterly 
direction  from  Yunnan  to  Kingyuan  in  Kwangsi.  It  here  meets  the 
river  Lieou  Kiang,  and  becomes  a  water  route  to  Lauchaufu,  which  is 
a  great  distributing  centre,  goods  from  the  west  being  sent  to  Yunnan 
and  Kweichow  provinces,  and  vice  versa.  At  Lauchaufu  the  route 
branches  into  two,  one  going  overland  in  a  north-easterly  direction  to 
Kweilin,  the  capital  of  Kwangsi,  and  thence  by  water  due  south  to 
s.  4 


50  History  ((ml  DisfriJmflon  of  Pkujue        [part  i 

Wuchowfu.       The    other    branch     is    by    river,    via    Tsainchaufu    to 

Wuchowfu. 

The  province  of  Yunnan,  at  the  time  of  M.  E.  Rocher's  visit,  was 

Condition  of       '"  '^  state  of  rebellion.     The  inhabitants,  chiefly  Mahom- 

Yunnan  in  nie(hins,  had  risen  against  the  Imperial  Government,  and 

1871  as  .  . 

observed  by        such  was  their  power  that  it  took  some  twenty  years  to 

M.  Rocher.  subdue    them.     The    traveller    found   large   tracts  of  the 

country  devastated  or  deserted,  and  everywhere  signs  of  depopulation 

and  of  the  ravages  of  warfare,  great  numbers  of  the  inhabitants  having 

been  killed  in  battle  or  afterwards  massacred.     To  the  miseries  of  war 

and  of  famine  Avere  added  those  of  pestilence,  the  infection  of  which  was 

often  carried  b}^  the  rival  armies  from  village  to  village,  and  from  town 

to  town.     What  proportion  of  the  depopulation  of  Yunnan  was  due  to 

fighting,  and  what  proportion  to  famine,  massacres,  and  pestilence,  is 

unknown,  but   their  combined   effect  Avas   to  convert  a  populous  and 

thriving  province  into  a  country  with  few  inhabitants,  and  one  which 

had  to  be  repeopled  by  immigrants. 

That  the  pestilence  was  plague  there  can  be  no  doubt.  M.  Rocher's 
description  of  the  disease  and  its  association  with  swellings  in  the 
armpit,  groin,  and  neck,  allow  no  other  conclusion.  The  following  is 
M.  Rocher's  account  of  the  disease :  v 

"  La  maladie  connue  au  Yiin-nan^  sous  le  nom  de  yang-tzii  \  v^  JT } , 
M.  Rocher's  et  qui  parait  n'etre  autre  que  la  peste  bubonique,  y  fait 
plague  in  chaque  annee   de   nombreuses   victimes ;    elle  sevit  aussi 

Yunnan.  quelquefois  dans  le  Laos  et  sur  la  frontiere  du  Kuei-chou. 

"  D'apres  les  renseignements  que  nous  avons  pu  obtenir  parmi  les 
notables,  cette  maladie  semble  venir  de  la  Birmanie,  d'oi^i  elle  est 
transmise  par  les  caravanes  qui  trafiquent  entre  les  deux  pays.  On 
n'est  pas  d'accord  sur  I'epoque  de  son  apparition  dans  le  Ytin-nan :  les 
uns  disent  (et  la  j)lus  grande  partie  de  la  population  est  de  cet  avis)  que 
le  centre  et  Test  de  la  province  n'ont  connu  le  fleau  qu'au  debut  de  la 
rebellion ;  d'autres  pretendent  qu'il  s'est  montre  dans  I'extreme  ouest 
jusqu'a  Ta-li-fu,  quelques  annees  auparavant.  En  supposant  que  cette 
derniere  hypothese  soit  vraie,  I'epidemie  a  du  passer  bien  legerement  dans 
ces  parages,  puisqu'on  n'en  a  pas  eu  connaissance  dans  les  autres  districts. 

"  Depuis  le  commencement  de  la  guerre  civile,  cette  terrible  maladie 
s'est  dechainee  avec  fureur  sur  la  province  et  continue,  encore  aujourd'hui 
que  la  province  est  paisible,  a  y  exercer  ses  ravages. 

^  Notes  sur  la  peste  an  Yiin-)i(in,  La  Province  Chitioise  du  Yiiii-nan,  par  Emile  Kocher. 
Deuxifeme  Partie,  p.  279. 


CH.  Ill]  Pkujue  in   Yunnan  51 

"  Ce  qui  ferait  croire  que  cette  epidemie  n'est  due  qu'aux  miasmes 
malfaisants  qui  s'exhalent  de  la  terre,  c'est  que  les  petits  animaux  qui 
vivent  dans  les  egouts  ou  sous  la  terre  sont  attaints  les  premiers,  les 
rats  par  exemple.  Des  qu'ils  se  sentent  malades,  ils  sortent  par  bandes, 
font  irruption  dans  I'interieur  "des  maisons,  courent  afFoles,  et,  apres 
quelques  tours  sur  eux-memes,  torabent  morts ;  le  plus  souvent  ils 
crevent  sous  les  planehers,  ce  qui  determine  dans  les  appartements 
des  odeurs  infectes,  dont  on  ne  decouvre  que  troj)  tard  la  cause.  Le 
meme  phenomene  se  produit  chez  tons  les  autres  animaux,  grands  et 
petits :  les  buffles,  les  boeufs,  les  moutons  et  les  chevres  sont  frappes  du 
meme  mal,  et  parfois  aussi  les  oiseaux  de  basse-cour,  mais,  parmi  ces 
derniers,  la  maladie  fait  moins  de  victimes.  A  notre  arrivee  dans  la 
province,  nous  refusions  d'aj outer  foi  aux  nombreux  temoignages  des 
indigenes,  en  les  mettant  sur  le  compte  de  leur  imagination  troublee  ou 
de  leurs  idees  superstitieuses ;  mais  quand  I'epidemie  eclata  dans  le 
district  meme  ou  nous  nous  trouvions,  il  nous  fut  facile  de  nous  con- 
vaincre  de  leur  veracite. 

"  Des  que  ces  symptomes  avant-coureurs  se  manifestent,  la  population 
ne  tarde  pas  a  etre  attaquee  a  son  tour.  On  prend  alors  les  precautions 
estimees  les  plus  efficaces  pour  se  garantir  dn  fleau.  Presque  partout, 
afin  de  purifier  les  maisons,  on  allume  du  feu  dans  toutes  les  chambres, 
et  dans  certains  districts  on  cesse  de  manger  du  pore. 

"  Chez  I'homme,  la  maladie  s'annonce  par  une  fievre  violente,  accom- 
pagnee  d'une  soif  intense ;  quelques  heures  apres,  une  tumeur  d'un  rouge 
fonce  commence  a  paraitre  aux  aisselles,  a  I'aine  ou  au  cou  ;  la  fievre 
s'accentue  de  plus  en  plus,  et  le  malade  ne  tarde  pas  a  perdre  connais- 
sance.  La  tumeur  grossit  d'habitude  jusqu'au  second  jour  et  reste 
ensuite  stationnaire.  A  partir  de  ce  moment,  le  malade  parait  reprendre 
ses  sens,  mais  il  est  encore  en  grand  danger ;  car,  si  la  tumeur,  jusqu'alors 
tres  dure,  devient  molle,  et  si  la  fievre  ne  diminue  pas,  il  est  considere 
comme  perdu ;  dans  le  cas  contraire,  si  la  tumeur  perce  en  dehors,  ce 
qui  amve  rarement,  il  y  a  espoir  de  le  sauver ;  mais,  arrive  a  ce  point, 
le  malade  est  si  affaibli  que,  bien  que  la  tumeur  ait  abouti,  il  meurt 
d'epuisement. 

"  Quelques  medecins  chinois  ont  essaye  d'inciser  ces  tumeurs ;  mais, 
soit  que  I'operation  ait  ete  mal  faite  ou  trop  tardivement,  bien  peu  de 
malades  y  survivent ;  quand  ils  sont  a  bout  de  ressources,  ils  ont  recours 
au  muse  qu'ils  ordonnent  a  la  derniere  extremite  et  a  fortes  doses. 

"  Pendant  notre  sejour  au  Ylin-nan,  nous  avons  vu  un  grand  nombre 
de  cas,  et  nous  devons  dire  que  la  plupart  ont  eu  un  denouement  funeste. 

4—2 


52  History  (iiid  Disfj-thnfion   of  Plague       [part  I 

Dans  les  endroits  on  la  peste  ne  fait  que  passer,  on  pent  estimer  que  le 
nonibre  de  ses  victinies  est  environ  de  4  a  6  pour  100 ;  tandis  que  dans 
d'autres  districts,  plus  rudement  eprouves,  la  population  est  complete- 
ment  decimee,  et  des  families  entieres  disparaissent  les  unes  apres  les 
autres.  Dans  les  parages  oil  re])id('nnie  sevit  avec  tant  de  violence,  les 
habitants  n'hesitent  pas  a  abandonner  leurs  demeures  et  leurs  recoltes 
sur  pied  ])oui-  aller  camper  sur  les  hauteurs  oil,  bien  souvent,  le  fleau 
les  poursuit. 

"Ce  qui,  a  notre  avis,  contribue  beaucoup  a  aggraver  cette  deplorable 
situation,  c'est  que  les  Chinois,  superstitieux  comme  ils  le  sont,  au  lieu 
d'enterrer  les  pestiferes,  se  contentent  de  les  placer  dans  des  bieres 
qu'ils  exposent  au  soleil,  soit  sur  la  pente  des  collines  ou  en  plein  champ. 
II  s'ensuit  que  les  gens  qui  voyagent  ou  circulent  dans  les  environs  des 
villages  empestes  sont  a  peu  pres  asphyxies  par  les  odeurs  nauseabondes 
que  repandent  les  cadavres  en  decomposition. 

"  Pendant  les  annees  1S71,  1872  et  1873,  nous  avons  remarque  que 
le  debut  de  lepidemie  se  manif'este  toujours  au  commencement  de  la 
plantation  du  riz,  c'est-a-dire  de  mai  a  juin :  apres  cette  epoque,  elle 
sevit  avec  vigueur  dans  les  localites  qu'elle  traverse.  Durant  I'ete,  qui 
est,  au  Ylin-nan,  la  saison  des  pluies,  elle  continue  de  se  propager  avec 
moins  d'activite ;  toutefois,  c'est  pour  reprendre  une  intensite  nouvelle 
a  I'epoque  de  la  moisson,  et  c'est  a  partir  de  ce  moment  jusqu'a  la  fin  de 
I'annee,  qu'elle  fait  le  plus  de  victimes. 

"  Un  fait  etrange,  que  nous  avons  observe  dans  plusieurs  endroits  au 
midi  et  au  nord  de  la  province,  c'est  que  I'epidemie,  au  lieu  d'englober 
tous  les  lieux  habites,  villes  et  villages,  qui  se  trouvent  sur  sa  route, 
passe  a  cote  sans  y  toucher,  les  franchit  meme,  et  revient  quelques  mois 
apres,  ou  I'annee  suivante,  frapper  I'endroit  oublie.  Voici  un  autre  fait, 
non  moins  curieux  que  le  precedent :  apres  s'etre  declaree  dans  presque 
tous  les  villages  disperses  dans  les  plaines,  I'epidemie  eclate  sur  les 
montagnes  ou  elle  produit  de  nombreux  ravages  parmi  les  aborigenes. 
D'apres  ce  que  nous  avons  vu  par  nous-memes  et  la  fa9on  irreguliere 
dent  la  maladie  se  presente,  elle  parait  importee  sur  les  hauteurs  par  les 
hommes  ou  femmes  qui  vont,  a  certaines  epoques  de  I'annee,  travailler 
dans  les  plaines.  C'est  surtout,  comme  nous  I'avons  dit  plus  haut,  apres 
la  plantation  du  riz  ou  quand  la  recolte  est  terminee  que  le  fleau  quitte 
le  pays  bas  pour  aller  sevir  sur  les  hauteurs. 

"  L'esquisse,  montrant  la  marche  suivie  par  la  maladie  pendant  les 
annees  1871,  1872  et  1873,  a  ete  dressee  d'apres  des  notes  officielles 
fournies  ])ar  les  fonctionnaires  des  lieux  pestiferes  et  d'apres  nos  propres 
renseignements." 


MAP    OF    YUNNAN     FU    AND    SURROUNDING    DISTRICTS. 

Showing  the  Course  pursued  by  the  Plague,  the  Districts  wherein  it  was  most  fatal 
and  those  through  which  it  merely  passed,   during  1871,   1872  and   1873. 

EXPLANATION. 
I  Starting  point  of  the   Plague  in    1871  and  1872. 

_._.....-     Course   pursued  by  the   Epidemic  in   1871  and  1872. 
Place  where  its  advance  ceased  in   1872. 
Starting  point  in   1872  and   1873. 

Course  pursued  by  the  Epidemic  in   1872  and  1873. 
Place  where  its  advance  ceased  in  1873. 
Districts  where  the  Epidemic  was  notably  fatal. 
Districts  merely  visited  by  the   Epidemic. 


II 
III 


54  Hiiitorji  anrj  Disfrihfffioit  of  Plague        [part  i 

An  earlier  but  similar  account  with  chart  by  M.  I^mile  Rocher  was 

translated  by  Dr,  now  Sir  Patrick  JManson,  medical  adviser  to  the  Colonial 

Office,  and  ajjpears    in    the  Medical  Reports  for  the   half-year  ended 

31st  March,  1878,  published  by  the  Inspector-General  of  the  Chinese 

Customs    Service.     The    chart    reproduced    here    shows    the  course    of 

the  epidemic  from  town  to  town  in  the  province  of  Yunnan.     It  will 

^  .^     .  be  noted  that  the  first  sign  of  the  disease  in  an  epidemic 

Epidemic  pre-  ^  _  '■ 

ceded  by  sick-  form  was  a  sickness  and  mortality  among  rats.  How  and 
taiity  among  when  plague  first  came  to  Yunnan  is  unknown.  It  evidently 
rats.  existed  there  before  the  Mahommedan  rebellion,  and  it  was 

the  conditions  of  warfare  which  brought  it  markedly  into  prominence. 
There  are  traditions  of  the  infection  having  been  imported  from  the 
western  frontier  of  Yunnan,  and  M.  Rocher  thinks  that  it  may  have 
been  introduced  from  Burma.  Possibly  Mahommedan  pilgrims  returning 
from  Mecca  in  the  early  part  of  the  19th  century,  when  plague  was 
prevalent  in  Egypt  and  Arabia,  may  have  introduced  it  into  Yunnan. 
That  this  journey  was  occasionally  undertaken  is  evidenced  by  the  fact 
that  Ma-hsing,  the  high  priest  of  the  Mahommedans  of  Yunnan,  and 
leader  of  the  rebellion,  visited  Mecca  in  1839,  travelling  from  Yunnan 
to  Bhamo  by  the  caravan  route,  and  then  by  boat  to  Rangoon,  where 
he  embarked  in  a  pilgi'ims'  ship.  Having  spent  some  time  in  the 
Sacred  City,  Ma-hsing  visited  Egypt  and  Constantinople  and  returned 
in  1846  to  Yunnan  by  the  river  of  Canton  or  West  River.  But 
against  this  view  of  the  importation  of  plague  by  pilgrims  in  the  19th 
century,  there  is  evidence  of  a  fatal  sickness  having  occurred  among 
rats  and  human  beings  in  Yunnan,  as  far  back  as  the  last  decade  of  the 
18th  century,  which  tends  to  indicate  that  some  portion  of  Yunnan 
had  been  an  endemic  centre  for  over  100  years  at  least. 

Baker  met  with  the  disease  in  his  travels  through  Yunnan  in  1877. 
Monsr.  Fenoullett,  Bishop  of  Yunnan,  states  that  in  1866  a  large  portion 
of  the  population  of  Yunnanfu  succumbed  to  plague,  and  M.  Rocher  in 
a  second  visit  to  Yunnan  found  that  plague  began  to  be  known  in  1840, 
but  long  before  that  time  it  had  existed  in  the  western  part  of  the 
province  without  prevailing  epidemically.  The  following  passage  found 
in  Hung  Liang-Kih's  Peh-Kiang-S/ii-Hwa^  bears  witness  to  this,  in- 
asmuch as  the  author,  who  was  born  in  1736  and  died  in  1809,  speaks 
of  his  contemporary  as  having  died  of  the  pest  in  Yunnan.  "  Shi 
Tau-Nan,    the    son    of  Shi   Fan,   now  the  Governor  of   Wang  Kiang, 

'  S'litttre,  Feb.  1(3,  1H99.     Note  by  Mr  Kumagusn  Minakata. 


CH.  Ill]  Plague  in  Pakhoi  55 

was  notorious   for   his  (poetic)  gift  and  was  only   36  years  old  when 

he   died Then    in   Chau-Chau   (in    Yunnan)    it    happened    that   in 

the  daytime   strange   rats  appeared   in    the    houses,    and    lying   down 

on   the  ground  perished  with   blood-spitting.     There  was  not  a  man 

escaped    instantaneous  death  after   being    infected   with   the    miasma. 

Tau-Nan   composed    thereon   a   poem    entitled   '  Death    of   Rats,'   the 

masterpiece    of  his ;    and    a   few  daj^s    after    he    himself  died   of  this 

queer  rat  epidemic." 

The  first  medical  account  of  plague  in  Southern  China  is  given  by 

Dr  Lowry  of       ^^  Lowry^  of  Pakhoi  in  1882,  the  year  he  was  first  stationed 

Pakhoi  gives       there  as  Medical  Officer  to  the  Customs.     His  Notes  on  an 

account  of  Epidemic  Disease  observed  in  Pakhoi  in  1882  are  extremely 

plague  in  valuable  because  of  the  very  careful  and  accurate  manner 

Southern  .  .  .        ^^        . 

China  at  in   which    the    disease    is   described,  and    because   of  the 

*    °'"  comparisons  made  between  it  and  the  plague  of  Yunnan 

and  of  Northern  India.     Dr  Lowry  also  observed  the  mortality  in  rats 

which  accompanies  the  disease. 

He  remarks  that  "  in  nearly  every  house  where  the  disease  broke  out 
the  rats  had  been  coming  out  of  their  holes  and  dying  on  the  floors." 
The  disease  was  not  new  to  Pakhoi,  nor  to  Lienchow,  a  city  about 
12  miles  distant.  In  1871,  Mr  T.  E.  Cocker,  a  Deputy  Commissioner  of 
Customs  at  Hongkong,  visited  Pakhoi,  and  at  the  time  of  his  visit  there 
was  a  severe  outbreak  of  the  disease,  accompanied  by  a  mortality,  not 
only  among  rats,  but  also  among  })igs  and  cattle.  Mr  Scott,  Consul 
General  of  Canton,  saw  cases  of  plague  in  Pakhoi  in  1879.  It  was  then 
called  the  "Yunnan  sickness"  by  the  Chinese.  Mr  Netten  Radcliffe,  of 
the  medical  department  of  the  Local  Government  Board  of  England,  in 
his  memorandum  on  the  progress  of  Levantine  plague  in  1878  and  1879 
records  some  important  information  regarding  plague  at  Pakhoi  derived 
from  Surgeon  A.  R.  Lynch's  journal  for  H.M.S.  Mosquito  on  the  Chinese 
Station,  1879.  It  is  accompanied  by  a  map  showing  the  presumed 
route  taken  by  the  plague  from  Pakhoi  to  Yunnan ;  and  though  the 
map  is  doubtless  correct  in  showing  the  localities  affected,  it  is  incorrect 
as  to  the  direction  of  the  route  by  which  the  plague  spread,  which  waf; 
originally  from  Yunnan  to  Pakhoi,  and  not  from  Pakhoi  to  Yunnan. 

Dr  Lowry  states  in  his  notes  that  "  the  epidemic  which  I  have 
observed  in  this  district  does  not  seem  to  be  an  old  disease,  as  it  occurred 
for  the  first  time  about  fifteen  years  ago,  and  since  that  time  has  occurred 

1  Imperial  Maritime  Cnstonix  Medical  Reportx  for  the  half-year  ended  30th  September, 
1882,  24th  issue,   1883. 


r)6  Historfi  and  DistributioH  of  Plague        [part  i 

at  certain  intervals,  the  last  severe  outbreak  being  in  1877.     I  am  told, 

however,  that  a  few  cases  occur  every  year,  but  my  short 

appeared  at        residence  has  not  given  me  an  opportunity  of  verifying 

Pakboi  in  ^\-^\^  statement."     The  plague  first  appeared  in  Pakhoi  in 

18(J7.     It  is  to  be  noted  that  this  was  at  a  time  when  the 

Mahommedan  rebellion  in  Yunnan  was  in  full  force  and  troops  raised  in 

Hainan  and  the  Pakhoi  district  were  engaged  at  the  seat  of  war. 

Pakhoi  is  not  a  large  town  nor  an  old  one.    The  population  to-day  is 

about  20,000,  and  it  dates  back  only  to  1852,  when  some 
Trade  route  i     i      i  t 

from  Pakhoi       Cantonese   merchants   settled    there.     It   seems  to  have 

0     unna    u.     ^h^Jven  fairly  well,  for  it  Avas  one  of  the  treaty  ports  agreed 

to  be  opened  to  foreign  trade  in  18(j0,  though  the  actual  opening  did 

not   take  place  till   some  years   later.     Its  principal   and   most  direct 

connection  with  Yunnan   is   to  be  seen   on   the  map  appended.     The 

route  is  long  and  difficult,  jjartly  by  land  and  partly  by  water. 

From  Pakhoi  to  Nanningfu  the  journey  had  to  be  accomplished 
overland,  from  Nanningfu  to  Pose  by  the  West  River  and  from  Pose  to 
Yunnanfu  again  overland.  Cotton  goods  are  the  principal  staple  article 
taken  from  the  port  of  Pakhoi  to  Yurmanfu,  and  there  they  are 
exchanged  for  tin  and  opium  which  are  brought  to  the  coast. 

During  the  Mahommedan  rebellion  trade  was  much  disturbed,  and 
under  the  })eculiar  conditions  it  is  less  likely  that  plague  was  imported 
from  Yunnan,  by  the  ordinary  limited  intercourse  of  traders,  into  the 
Pakhoi  district  and  the  island  of  Hainan,  than  by  the  movement  of 
Chinese  troops,  many  of  which,  as  previously  stated,  \vere  drawn  from 
the  island  of  Hainan  and  from  the  western  prefectures  of  Kwangsi  and 
Kwantung  close  to  Yunnan.  No  doubt  there  would  be  many  traders 
with  the  troops  for  the  purpose  of  supply.  This  latter  view  of  the 
manner  in  which  plague  spread  from  Yunnan  to  Pakhoi  appears  to 
be  held  by  the  Chinese,  and  it  is  more  in  accordance  with  that  which  is 
known  concerning  the  rapid  spread  of  epidemics  from  one  distant 
locality  to  another,  namely,  that  these  epidemics  of  a  sudden  and  rapid 
growth  are  usually  associated  with  large  movements  of  population.  An 
epidemic  of  plague  occurs  in  Yunnanfu  in  1866,  which  decimates  the 
population  while  they  are  in  the  midst  of  war,  and  in  1867  Pakhoi, 
one  of  the  homes  of  returning  troops  from  Yunnan,  is  attacked. 

The  distance  between  Yunnanfu  and  Pakhoi  is  about  oOOO  lis,  and 
it  takes  about  48  day  stages  to  travel  from  one  to  another.  What 
intervening  localities  w^ere  attacked  is  unknown,  but  it  is  unlikely 
they  escaped. 


CH.  Ill]  Eastward  Advance  of  Plague  hi- 

Once  the  disease  was  established  in  Pakhoi  it  seems  to  have  become 

endemic   for   18  years.     There  was  a  severe  epidemic  in 

demic  in  1877.     Every  year  it  recrudesced  and  prevailed  more  or 

Pakhoi  from       j^gg  from  March  to  June  until  1884,  when  from  the  reports 

1867  to  1884.  ^  ^         r^  ■ 

of  the  Medical  Officer  of  the  Customs  it  seems  to  have 
ceased  until  re-infected  in  1894.  This  spontaneous  cessation  of  the 
plague  is  a  phenomenon  which  has  not  infrequently  manifested  itself  in 
small  towns,  occasionally  in  large  cities,  and  rarely  in  commercial  towns, 
such  as  Smyrna  and  other  busy  entrepots  of  trade  in  close  communication 
with  infected  centres. 

Although  Pakhoi  seems  to  have  enjoyed  a  freiedom  from  plague  for 
PiagTie  not  ^^  years,  from  1 884  to  1894,  the  disease  was  far  from  being 

extinct  in  ad-  extinct ;  it  not  only  continued  to  prevail  in  the  ])rovince  of 
lecture  to  that  Yunnan  and  at  varying  intervals  in  the  neighbouring 
of  Pakhoi.  towns   of  the   Kweichow,   Kwangsi,  and   Kwantung  pro- 

vinces, but  it  was  also  present  in  the  adjoining  prefectures  to  that 
in  which  Pakhoi  is  situated.  They  are  localities  away  from  European 
contact,  and  it  is  only  incidentally  that  plague  is  discovered  to  prevail 
in  them.  Distant  from  the  coast  ports,  from  the  customs  stations,  or 
from  missionary  outposts,  news  becomes  exceedingly  scanty,  infrequent 
and  unreliable,  and  occurrences,  however  important  or  disastrous  they 
may  be  to  the  localities  affected,  come  but  rarely  to  the  ears  of 
Europeans.  It  is  certain  that  from  1890  a  gradually  extending  area 
of  the  western  parts  of  Kwangsi  and  Kwantung  was  becoming  affected 
with  plague. 

Plague  pi'evailed  at  Lungchow,  Pose,  Nanningfu  and  Taipingfu  in 
1890'.  It  again  prevailed  at  Lungchow  in  1893.  As  soldiers  were  the 
first  victims  of  the  outbreak,  Dr  Siminonds,  who  was  at  Lungchow  at  the 
time,  was  of  opinion  that  the  disease  was  imported  into  the  garrison  of 
Lungchow  from  Liencheng,  a  frontier  town  on  the  borders  of  Yunnan. 
There  was  another  epidemic  in  Lungchow  in  1894,  which  was  evidently 
a  recrudescence  of  the  outbreak  of  the  previous  year. 

Plague  occurred  at  Kaochao  in  1891,  and  at  Ampu,  which  is  east  of 
Pakhoi.  in  1891-.  It  was  also  prevalent  at  Mouiluk  in  1890  and  1893. 
Mouiluk  is  south  of  Kaochao  and  near  the  French  possession  of 
Kwan-shan-w^an.     It  is  about  300  miles  south-west  of  Canton. 

•  Imperial  Maritime  Ciistoni.i  Mi-diral  Reports  for  the  year  ended  ;31st  March,  1890, 
38th  and  39th  issues,  1894. 

-  Imperial  Maritimi-  Custuius  Medical  Ixeporta  for  the  year  ended  30th  Sejiteniber, 
1893,  45th  and  46th  issues,  1895. 


58  History  and  Distribution  of  Plague       [part  i 

If  we  now  go  back  to  the  Yunnan  province  we  shall  find  that 
as  soon  as  the  Customs  opened  a  station  at  Mengtze,  one  of  the  principal 
towns  in  the  south-east  of  the  province,  plague  is  immediately  reported 
as  epidemic  there.  It  is  the  usual  history  of  plague  in  China.  Nothing 
is  heard  of  it  in  a  particular  locality  until  that  locality 
Mengtze,  is  visited  by  a  European.    The  disease  prevailed  in  Mengtze 

1874  1893.  £^^  many  years  prior  to  the  advent  of  the  Customs  officers, 

but  it  was  not  discovered  and  described  by  a  European  medical  man 
until  1894. 

Mengtze  is  situated  in  the  south-eastern  part  of  Yunnan,  in  latitude 
23"  34'  N.,  and  longitude  103  3(i'  E.  Like  most  of  the  princi})al  towns 
of  Yunnan  it  is  in  the  middle  of  a  large  plateau  elevated  4500  feet 
above  sea-level  and  surrounded  by  mountains  rising  from  6000  to  9000 
feet  above  the  sea-level.  The  town  is  the  centre  of  a  large  traffic 
between  Yunnan  and  the  province  of  Kwangsi,  as  well  as  between 
Yunnan  and  Tonking. 

The  Imperial  Chinese  Customs  opened  a  station  at  Mengtze  in  1899, 
and  the  European  officers  on  their  arrival  found  plague  prevailing.  It 
had  recurred  every  year  in  Mengtze  since  1885,  and  first  appeared  there 
in  1874.  There  was  a  severe  epidemic  in  1892,  but  according  to  native 
reports  the  epidemic  of  1893,  which  continued  during  the  months  of 
June,  July  and  August,  was,  compared  with  previous  epidemics,  not 
particularly  severe.  Dr  Michoud^  in  describing  the  epidemic,  remarks 
that  "  however,  out  of  an  estimated  population  of  10,000  or  12,000 
a  thousand  people  died.  Carried  outside  the  dwellings,  the  victims 
of  plague  lay  dead  or  dying  unheeded  in  the  streets  or  set  in  rows 
leaning  against  the  city  wall."  Dr  Michoud  continues:  "In  some  places 
whole  families  disappear.  At  the  beginning  of  the  last  epidemic,  we 
were  called  to  the  young  son  of  the  Chengtai  (Chinese  General)  of 
Mengtze.  The  poor  boy  had  just  been  given  over  by  the  native  doctors, 
who,  probably  from  fear  of  displeasing  the  father,  would  not  declare  the 
nature  of  the  disease.  As  we  were  aware  of  a  case  of  yang-tzu-ping 
ha\ing  already  occurred  in  the  Chengtai's  yanien — considering,  too,  the 
rapid  evolution  and  extreme  gravity  of  every  symptom  exhibited  by  the 
little  patient — disregarding,  at  the  same  time,  the  hypothesis  of  heat- 
stroke or  pernicious  intermittent  fever,  we  had  no  hesitation,  in  spite  of 
the  absence  of  any  external  adenitis  (and  to  the  great  displeasure  of  the 
father),  in  diagnosing  yang-tzu-ping.     Although  willing  to  do  our  best, 

1  Imperial  Maritime  Cuistoms  Medical  lii'ports  for  the  year  ended  30th  September,  1894, 
47th  and  48th  issues,  1895. 


Cii.  Ill]  Tlie   Waterways  of  Canton  59 

we  insisted  on  the  probable  failure  of  any  treatment,  and  urged  the 

necessity  for  immediate  and  energetic  disinfection  in  order-  to  ward  off 

further   diffusion    of  the    disease.     The    boy    died    shortly   afterwards. 

None  of  the  measures  advised  were  taken  because  the  native  quacks 

denied  the   accuracy  of  our  diagnosis.     Doubtless   the   failure   of  our 

treatment  had  discounted  the  value  of  our  advice.     However  that  may 

be,  the  Chengtai,  an  old  warrior  who  had  spent  his  whole  life  in  Yunnan, 

and    had    passed    unscathed    through    the    previous    epidemics    which 

decimated  the  country,  was,  in  a  few  days  after  the  death  of  his  son, 

attacked  by  yang-tzu-ping  and  speedily  perished.     Some  of  his  wives, 

many  of  his  relations  and  servants,  were  in  succession  attacked,  all  the 

cases  ending  fatally.     The  people  that  died  from  yang-tzu-ping  in  that 

yamen  before  the  end  of  that  epidemic  numbered  at  least  25." 

The   epidemic  described  at  Mengtze,  following  as  it  did  a  severe 

epidemic  in  1892,  occurred  in  May,  June  and  July  of  1893. 

Nanningfu          Two  months  later  the  disease  is  stated   to  be   epidemic 

and  Kwaium       j^  Lungchow  and  in  many  towns  of  the  Kwangsi  province, 
in  1893.  ^  .  -^       .  ^     y      . 

such  as  Nanningfu  and  Kwaium,  the  latter  of  which  is  not 

more  than  200  miles  from  Wuchowfu. 

It  is  clear  that  plague  was  extensively  diffused  at  that  time.  It 
was  epidemic  in  Mengtze  in  1893,  and  for  several  years 
Canton  in  previously.     It  was  also  epidemic  in  some  of  the   south- 

western towns  of  Kwangsi,  especially  those  situated  on 
the  West  or  Canton  River,  and  it  was  more  or  less  prevalent  in  the 
south-western  districts  of  Kwantung. 

The  existence  of  plague  in  these  places  excited  no  interest  beyond 
the  localities  affected,  and  it  was  not  until  the  disease  reached  the 
delta  of  the  West  River  and  attacked  Canton,  the  capital  of  Kwantung, 
and  an  epidemic  of  exceptional  proportions  began  to  devastate  the  city 
in  the  spring  of  1894,  that  the  fact  that  plague  in  a  dangerous  form 
existed  in  China  became  generally  known  to  the  Europeans  living  in 
that  country. 

Canton  is  the  chief  port,  as  well  as  the  largest  and  most  important 

city  in  Southern  China.  It  is  the  capital  of  the  Kwantung 
Canton  con-  •  i  .•  -,    ,■  -i         j.-j.ji 

nected  with        province  and  contains  a  population  variously  estimated  at 

thecMef  11    to  2   millions.     Situated  in  23'  of  latitude  N.,  and 

towns  and  "         -,   ,>    ^  •         ^  iii  c      ^         i\         ^    -n-  •       • 

districts  of         113   14    longitude,  on  the  banks  oi  the  rearl  Kiver,  it  is 

Kwangsi  and      gome   70   miles  from   the   coast,  and   in   the   centre   of  a 
Kwantung. 

district  traversed  and  intersected  with  waterways,  formed 

by  the  convergence  of  several   rivers  from  the  north,  east,  and  west. 

By   this  network   of  waterways.  Canton    is  connected   with   the   chief 


/^ 


60  ffistort/  inul  /)isfrif>fffl(Ht  (tf  Phf/ire        [part  I 

towTis  and  districts  in  Kwangsi  and  Kwantung.  At  the  mouth  of  the 
Pearl  River  lies  Macao  on  one  side,  and  the  colony  of  Hongkong  on  the 
other. 

The  inland  water  communications  of  Canton  extend  westward  to 
the  borders  of  Yunnan  and  Kweichow.  The  Sikiang  or  West  River,  or 
Canton  River  as  it  is  sometimes  called,  is  navigable  for  small  steamers 
as  far  as  Wuchowfu.  From  there  to  Nanningfu  the  passage  is  more 
difficult  on  account  of  some  dangerous  rapids,  but  native  boats  make 
it  successfully,  and  ply  between  the  two  towns.  From  Nanningfu  to 
Pose  the  river  is  suitable  for  light  draught  boats,  which  are  busily 
engaged  in  carrying  produce  to  and  fro.  Pose  is  on  the  borders  of 
Yunnan,  and  the  produce  reaching  it  by  boat  is  taken  by  pack  animals 
overland  to  Mengtze. 

\Vest  of  Nanningfu  a  branch  of  the  river  leads  to  Taipingfu  and 
Lungchow.  It  will  be  seen  from  the  map  that  Mengtze  and  Lungchow, 
both  infected  centres  of  plague,  are  on  the  lines  of  direct  communication 
with  Canton.  The  West  River  is  the  natural  and  most  convenient 
trade  route  for  produce  and  traffic  from  Yunnan,  Lungchow,  and  the 
greater  portion  of  the  Kwangsi  province,  but  as  jjreviously  stated, 
notwithstanding  the  advantages  of  this  route,  it  used  not  to  be  favoured 
by  Chinese  merchants,  who  preferred  to  take  their  merchandise  ft-om 
Nanninsrfu  overland  to  Pakhoi,  rather  than  direct  to  Canton.  The 
reason  for  this  was  partly  because  it  was  a  shorter  route  to  the  coast, 
but  mainly  because  of  the  numerous  likin  charges  between  Nanningfu 
and  Canton,  there  being  no  fewer  than  sixteen  likin  stations.  This  was 
altered  in  1891,  and  the  system  of  traffic  introduced,  which  resulted  in 
a  greater  use  of  the  West  River  for  the  conveyance  of  produce  and 
passengers  both  to  and  from  Canton. 

Whether  plague  reached  Canton  from  the  infected  towns  and 
villages  of  the  south-western  part  of  Kwantung,  or  direct  from  Yunnan 
and  Kwangsi  by  the  West  River,  is  unknown.  Probably  the  infection 
arrived  by  both  channels,  but  whichever  was  the  first,  the  original 
source  was  Y'unnan.  Fatshan,  a  town  situated  on  the  delta  of  the 
West  River  and  a  few  miles  from  Canton,  is  said  to  have  been  infected 
in  1893.  It  is  the  custom  of  the  Chinese  to  send  their  dead  to  be 
buried  in  their  native  village  or  town,  and  the  infection  at  Fatshan 
is  attributed  by  them  to  bodies  of  persons  who  died  of  plague  at 
Mengtze  having  been  sent  to  Fatshan  for  burial  in  badly  fitting  coffins. 
The  first  ca.ses  in  Fatshan  occurred  in  families  who  were  connected 
with  Mengtze.  It  has  already  been  noted  that,  both  at  Mengtze  and 
Lungchow,  plague  occurred  among  the  militar}-  stationed  at  each  place, 


CH.  Ill]  Plague  in  Canton  61 

and  it  is  a  curious  fact  that  the  first  case  seen  in  Canton  by  a  European 
ph^^sician  was  in  the  family  of  a  soldier. 

The  first  recorded  case  of  plague  in  Canton^  occurred  on  January 

16th,   1894,  when   Dr  Mary  Niles  was  called  in  to  see 

ca^n  in  General  Wong's  daughter-in-law,  who  was  reported  to  be 

Januaxy,  sufferinsf  from  a  "  boil,"  and  who,  when  seen,  was  found  to 

1894. 

have  a  very  painful  swelling  in  the  inguinal  region,  a 
temperature  of  104*8°  with  a  pulse  of  160,  and  a  petechial  eruption. 
The  patient  recovered,  but  the  bubo,  owing  to  sinuses  forming,  took  a 
very  long  time  to  heal.  Out  of  seven  cases  seen  by  Dr  Mary  Niles  up 
to  May  2nd,  in  no  fewer  than  four  purpuric  spots  appeared  before  death. 
In  a  number  of  cases  met  with  the  illness  was  of  a  light  character ;  for 
instance  Dr  Niles  records  a  case  in  which  "  a  lady  came  in  a  chair  but 
walked  into  the  office.  She  looked  perfectly  well,  temperature,  pulse 
and  digestion  normal.  She  said  she  had  fever  six  days  before,  and  the 
following  day  when  taking  a  bath  discovered  a  swelling  in  the  inguinal 
region,  of  which  she  had  not  been  previously  aware,  and  which  caused 
her  no  pain.  I  examined  the  bubo  and  saw  for  myself."  This  case  is 
suggestive  of  other  similarly  mild  cases,  and  the  likelihood  of  these 
occurring  at  an  early  stage  of  the  outbreak  without  attracting  any 
special  attention.  Dr  Niles  further  states :  "  It  has  been  noticeable  to 
the  people  that  rats  in  infected  houses  have  died.  In  the  house  where 
the  child  from  the  school  was  visiting  when  she  took  the  disease 
thirteen  dead  rats  were  swept  out  one  morning... One  of  the  officials, 
I  am  told,  offered  10  cash  for  every  dead  rat  brought  to  him.  He  had 
collected  35,000  in  one  month ;  2000  were  brought  to  him  in  one  day." 
It  was  only  towards  the  end  of  March  of  1894  that  the  disease 
began  to  attract  attention.  Dr  Alexander  Rennie  reports^  that  "  a  few 
stray  cases  occurred  in  the  beginning  of  March,  but  it  was  not  until 
the  end  of  the  month  that  attention  was  awakened  on  account  of  its 
fatal  prevalence  in  a  })()()r  neighbourhood  near  the  south  gate  of  the 
city,  and  also  in  Nan-sheng-li,  a  quarter  occupied  by  Mahommedans, 
among  whom  the  mortality  was  very  high.  At  this  time  the  type  of 
the  disease  was  exceedingly  severe — of  those  attacked  quite  80  "/(>  dying. 
Towards  the  middle  of  April  the  cases  we  saw  were  of  a  milder  type, 

1  Plague  in  Canton,  by  Mary  Niles,  M.D.,  The  China  Missioiuinj  Journal,  June,  1894, 
p.  116. 

-  Report  on  the  plague  prevailing  in  Canton  during  the  spring  and  summer  of  1894, 
by  Alexander  Rennie,  M.A.,  M.B.,  CM.,  Imperial  Customs  Maritime  Report  for  tlie  year 
ended  30th  September,  1894,  47th  and  48th  issues,  1895. 


62  History  and  Disfrihuffoa  of  Plague        [part  i 

but  the  disease  subsequently  became  more  severe,  and  extended  its 
boundaries  to  other  parts  of  the  city  and  also  to  Honam,  the  maximum 
niurtality  being  reached  about  the  middle  of  May... Rain  fell  copiously 
during  the  month  of  May  and  beginning  of  June,  so  that  many  streets 
were  under  water ;  the  temperature  remained  comparatively  low.  But 
both  these  factors  seemed  to  favour  the  propagation  of  the  disease,  as 
bv  the  beginning  of  June  it  was  rife  in  the  western  suburbs  as  well  as 
in  the  surrounding  towns  and  villages.  It  is  impossible  to  give  any 
correct  estimate  of  the  mortality,  as  no  official  records  of  burials  are 
kept.  Comparing  the  estimates  obtained  from  various  sources,  we 
believe  the  mortality  from  the  beginning  of  the  epidemic  to  the  middle 
of  June  (the  date  of  writing)  to  have  been  about  40,000. 

"Although  a  goodly  number  of  well-to-do  people  fell  victims  to  the 
pestilence,  the  chief  sufferers  were  the  poor,  over-crowded  and  badly 
housed.  The  people  who  escaped  the  scourge  in  the  most  marked 
degree  were  those  living  in  upper  stories  and  the  boating  population. 
With  the  exception  of  those  put  in  boats  after  falling  sick,  scarcely  a 
case  was  noted  on  the  river.  Many  well-to-do  people,  observing  this 
immunity,  removed  from  their  houses  and  made  their  homes  on  the 
river.  Judging  from  this  circumstance,  therefore,  and  also  from  the 
fact  that  rats  living  in  the  ground  and  drains  were  the  first  animals  to 
fall  victims,  we  infer  that  the  specific  poison  emanated  from  the  soil. 
What  the  specific  poison  may  be  is  not  determined,  but  no  doubt  the 
insanitary  conditions  referred  to,  exaggerated  by  a  prolonged  drought, 
provided  a  specially  suitable  nidus  for  its  growth  and  dissemination. 

"  The  immunity  enjoyed  by  residents  on  the  foreign  settlement  of 
Shamien  is  remarkable,  seeing  that  it  is  separated  only  by  a  creek  some 
20  yards  wide  from  houses  where  cases  of  plague  occurred.  Not  only 
did  foreigners  living  on  the  settlement  enjoy  excellent  health,  but  no 
case  of  plague  occurred  among  their  servants  living  on  the  premises. 
The  rats  also,  up  to  the  time  of  writing,  remain  healthy  and  lively." 

I)r  Rennie  further  states  in  this  report  that  on  the  outbreak  of  the 
disease  occurring  in  Canton  many  persons,  especially  the  well-to-do, 
removed  to  the  country,  thus  forming  fresh  foci  for  its  dissemination ; 
and  in  the  same  way  the  outbreak  in  Hongkong  no  doubt  arose  from 
persons  having  migrated  from  Canton  to  Hongkong  while  actually 
suffering  from  the  disease,  or  during  the  short  incubation  period. 

Dr  Mary  Niles  also  states  that  "  patients  went  home  to  the  country 
in  passage  boats,  some  died  in  the  boats,  and  others  in  their  native 
towns." 


CH.  Ill]  Plague  in  HongTiong  63 

Under  such  circumstances  and  from  such  a  centre  as  Canton,  which 
communicates  with  so  many  places,  the  infection  was  bound  to  be 
disseminated. 

The  largest  and  most  important  European  possession  near  Canton  is 

Hongkong,  situated  at  a  distance  of  only  some  80  miles, 

«ie°fargeft         ^^^^    daily  river   communication    with    Canton    both    by 

and  most  steamers  and  junks.     Hongkong,  on  account  of  its  position 

European  at  the  mouth   of  the   Pearl   River,  its  population   being 

possession  mainly   Cantonese,   and    the  great  and   increasing   traffic 

near  Canton.  -^  "  .  ^ 

with  Canton,  has  been  suggestively  called  the  suburb  of 

Canton.     The    extent   of  intercourse  between   the   two  ports   may  be 

gathered  from  the  fact  that  nearly  half-a-million  of  people  pass  each 

way  to  and  fro  annually,  and  some  4000  river  steamers  and  8000  junks 

annually  enter  the  port  of  Hongkong  from  the  Canton  and  West  River 

district,  most  of  them  coming  from  Canton  and  its  neighbourhood. 

Under  such  conditions  it  is   not   surprising   that  whatever  affects 

Canton  is  not   long  in  making  itself  felt  at  Hongkong. 

covered  in  In  1902  when  cholera  broke  out  in  Canton  there  was  only 

Hongkong  in      g^j^  interval  of  a  few  weeks  before  the  disease  appeared  in 
May,  1894.  .  .  . 

Hongkong.     And  so  it  was  with  plague  in  1894.     As  soon 

as  the  disease  was  well  established  in  epidemic  form  in  Canton,  it  was 

discovered  to  be  present  in  Hongkong. 

Although  there  is  no  positive  evidence  of  the  first  cases  of  plague 
coming  from  Canton,  rather  than  from  the  other  affected  areas  in  its 
vicinity  or  from  Pakhoi,  yet  as  large  numbers  of  the  inhabitants  in  order 
to  escape  plague  were  fleeing  from  Canton  to  Hongkong,  the  probabilities 
are  greatly  in  its  favour,  particularly  so  when  the  enormous  ordinary 
traffic  is  taken  into  account,  together  with  the  circumstance  that 
detection  of  sick  people  entering  the  colony  is  impossible,  because 
there  is  no  system  of  enquiry  as  to  sickness,  nor  is  there  any  inspection 
of  passengers  on  steamers  and  junks  from  Canton  or  from  the  West 
River. 

Dr  Lowson,  in  his  report  on  the  epidemic  of  bubonic  plague  in 
Hongkong  in  1894^  is  of  opinion  that  the  disease  was  imported  from 
Canton  rather  than  from  Pakhoi,  where  it  did  not  prevail  until  the 
latter  part  of  the  spring,  and  between  which  and  Hongkong  the  traffic 
is  insignificant  compared  with  that  between  Hongkong  and  Canton. 
Once  introduced  into  Hongkong,  the  disease  caused  the  greatest  alarm, 

1  The  Epidemic  of  Bubonic  Plague  in  Hongkong,  1894,  Medical  Report,  by  James  A. 
Lowson,  M.B.,  Medical  Officer  in  charge  of  Epidemic  Hospital,  Hongkong,  1895. 


64  Hisf<H'!i  find  Disfribufion  of  Plague        [part  I 

but  the  epidemic,  though  severe,  is  not  to  be  compared  in  intensity 

with  that  in  Canton,  even  if  the  lowest  estimate  of  40,000  be  accepted 

as  the  highest  number  of  deaths.     Many  in  Canton  have  estimated  the 

deaths  from  plague  in  that  city  in  1894  to  have  been  between  80,000 

and  100,000.     The  deaths  in  Hongkong  did  not  exceed  8000. 

It  was  in  the  Hongkong  epidemic  of  1894  that  the  causal  agent 

of  plague,  the   plague   bacillus,  was  discovered  by  Dr  S. 

baciUu^i^-       Kitasato  of  Tokyo,  on  June  14th.     Later  Dr  Yersin  made 

covered  in  independently  a  like  discovery  in  Hongkong.     The  Hong- 

Hongkong-  by  ^      .         .  .  "^  . 

Dr  s.  Kitasato     kong  epidemic  began  in  May  and  ended  in  August,  and 

DrVe^sm^^       its    incidence    was    proportionately    more    severe    on    the 

female  portion  of  the  population  than  on  the  male.    Macao 

did  not  suffer  epidemically  from  the  disease  until  April,  May  and  June 

of  1895.     During   the  winter   of   1894   and    1895   there 
Plague  in  ... 

Macao  in  prevailed  a  fatal  epidemic  which  attacked  the  respiratory 

^    ■  organs,  and   which   was  believed   to  be   influenza.     It   is 

worth  noting  that  this  was  at  a  time  before  the  pneumonic  type  of  plague 
was  recognised  as  a  variety  of  the  disease.  The  first  case  of  bubonic 
plague  which  came  under  the  notice  of  the  Portuguese  authorities  was 
an  imported  case  from  Hongkong,  and  to  this  source  is  ascribed  the 
origin  of  the  epidemic ;  but  as  the  case  came  under  the  care  of  the 
sanitary  authorities  the  next  day  after  arrival,  also  as  there  was  a  high 
mortality  among  the  Chinese  with  no  means  of  ascertaining  the  exact 
cause  of  death,  and  as  the  epidemic  quickly  followed  the  introduction  of 
this  single  case,  which  is  an  unusual  occurrence  with  plague,  whose 
progress  at  the  beginning  is  generally  slow,  it  is  likely  that  Macao  was 
infected  earlier.  The  epidemic  reached  its  acme  in  April  and  May,  and 
disappeared  in  June,  and  returned  in  1897  and  1898.  From  the  position 
of  Macao  and  its  intercourse  with  Canton,  Pakhoi,  Hongkong,  and  the 
villages  of  the  delta,  it  could  only  be  a  matter  of  time  for  it  to  be 
infected  by  people  coming  from  one  or  all  of  these  places. 

With  Canton,  Hongkong,  Macao  and  Pakhoi  infected  with  plague, 
Canton  and  i^  ^^''^s  not  long  before  the  disease  became  extensively 
Hongkong  be-  diffused  and  the  whole  of  the  southern  coast  of  China 
come  centres        ■  i     i      mi  •  />  c<        i  rM.  • 

of  distribution     invaded.    The  accompany  mg  map  of  Southern  Chma  shows 

of  plague.  ^j^g  course  of  plague  in  its  advance  from  Yunnan,  and  the 

distribution  of  the  disease  in  this  region  up  to  the  year  1902. 

The  two  most  important  emporia  of  China  are  Canton  and  Hong- 
kong, and  every  j^ear  but  1895  the  disease  has  recurred  in  Hongkong 
and  Canton. 


CH.  Ill]       The  Marts  of  Canton  and  Hongkong  65 

Admirably  situated  for  commerce,  Canton  and  Hongkong  are  the 
great  marts  and  distributing  ports  for  the  produce  of  Southern  China ; 
and  Canton  sends  its  merchandise  down  by  the  Canton  River  on  large 
and  small  native  craft  to  Hongkong,  where  it  is  stored  in  large  ware- 
houses until  ships  arrive  to  take  it  away  in  exchange  for  the  cargoes 
they  bring.  Hongkong,  though  not  more  than  sixty  years  old,  possesses 
one  of  the  busiest  harbours  in  the  world,  and  has  trade  connections,  not 
only  with  the  southern  ports  of  China  and  the  neighbouring  islands  of 
the  Pacific  and  Chinese  Seas,  but  also  with  India,  Australia,  Japan,  and 
America. 

It  has  already  been  stated  that  it  was  from  Canton  and  the  province 
of  Kwantung  that  Hongkong  became  infected  with  plague  in  1894,  and 
from  these  sources  it  continues  periodically  to  receive  fresh  infection. 
Plague  since  1896  has  also  become  endemic  in  Hongkong.  A  great 
commercial  centre  continually  exposed  to  fresh  infection,  and  in  which 
plague  is  endemic,  is  apt  to  be  dangerous  to  places  with  which  it  is 
in  frequent  communication,  and  it  has  thus  happened  that  Hongkong, 
besides  being  a  great  distributor  of  merchandise,  has  become  also  an 
active  centre  for  the  distribution  of  plague.  Sea-going  ships  have 
conveyed  the  infection  over  the  seas  to  India,  Australia,  Japan  and 
America,  and  coasting  steamers  have  distributed  it  to  adjacent  ports. 
It  has  not  always  been  possible  to  indicate  the  ship  that  conveyed  the 
infection  or  the  exact  agent  by  which  the  infection  was  carried,  whether 
by  man,  by  animals,  by  infected  clothing,  or  by  infected  merchandise ; 
but  it  is  possible  to  exclude  the  infection  being  conveyed  in  any  other 
way  to  Japan,  Australia,  and  America,  and  there  is  sufficient  evidence 
to  leave  no  doubt  as  to  the  infection  being  carried  by  shipping  having 
commercial  relations  with  infected  ports  in  Southern  China. 

Hongkong  is  separated  from  most  places  b}'^  the  sea,  and  the 
infection  has  not  passed  overland  to  China,  but  has  followed  the  trade 
routes  of  the  sea. 

It  is  a  very  remarkable  fact  that  plague  has  not  spread  very  far 
inland  in  China,  and  that  hitherto  its  chief  ravages  have  been  limited 
comparatively  more  or  less  to  that  portion  of  the  country  near  the  coast. 
The  infection  on  land  has  followed  chiefly  the  routes  of  busiest  inter- 
course. There  are  no  railways  in  Southern  China,  and  the  disease  has 
made  no  extensive  inroads  into  the  interior  of  the  country,  except  in 
those  districts  in  which  their  waterways  connect  them  with  infected 
localities.  In  the  case  of  the  infected  provinces  of  Kwangsi  and 
Kwantung,  and  Fokien,  a  range  of  hills  which  forms  a  natural  boundary 
s  5 


66  Ilisfori/  (1)1(1  Dififrihiition  of  Plague       [part  i 

between    the    north    and    the   south,  and   which    restricts   commercial 

activity  between  them,  also  prevents  plague  from  passing  northwards. 

But  apart  from  this  natural  obstruction  it  seems  to  be  a  characteristic 

of  plague  not  to  spread  much  beyond  the  towns  and  villages  on  the  more 

frequented  roads  of  trade. 

The  precise  date  and  manner  of  the  arrival  of  plague  infection  at 

Bombay  are  unknown.  There  is  constant  trade  intercourse 
Plague  at  '' 

Bombay  in  between  Bombay  and  Hongkong,  the  ships  of  Hongkong 

taking  the  produce  of  Canton  and  the  provinces  of  Southern 
China  to  Bombay,  and  the  ships  of  Bombay  taking  the  produce  of 
Western  India  to  Hongkong.  The  disease  may  have  been  introduced 
by  some  one  infected  among  the  crew  of  a  steamer  coming  from  Hong- 
kong, or  by  infected  rats,  or  possibly  infected  cargo.  It  has  happened 
even  as  late  as  1902  for  plague  to  be  imported  from  Bombay  to  Hongkong 
by  these  ships  and  for  the  disease  not  to  be  suspected  by  the  captain, 
and  it  has  also  happened  for  plague-stricken  rats  to  have  been  conveyed 
in  this  way  from  Bombay  to  Hongkong.  But  before  plague  broke  out 
in  Bombay  in  1896  there  was  so  little  suspicion  of  the  possibility  of 
the  disease  being  conveyed  from  Hongkong  to  Bombay  direct  before 
attacking  intervening  ports  that  no  alarm  was  felt  in  this  direction; 
nor  did  there  seem  grounds  for  that  alertness  essential  for  the  discovery 
of  first  cases  and  the  protection  against  importation.  Bombay  had  not 
been  attacked  by  plague  for  nearly  200  years,  though  the  disease  had 
prevailed  in  Gujarat,  Cutch,  Kathiawar,  Rajputana  and  Sind  from  1812 
to  1821,  in  Kumaon  and  Garhwal  on  the  slopes  of  the  Himalayas 
in  1823,  1834,  1847,  1876,  1884  and  1893,  and  in  Marwar,  Jodhpur, 
Rajputana  and  Pali  in  1836  and  1837. 

Bombay  also  remained  free  of  the  disease  when  it  was  epidemic  in 
Mesopotamia  as  recently  as  1891-92,  which  is  a  country  much  nearer  to 
Bombay  than  China.  With  such  an  experience  there  was  an  inclination 
to  think  that  Bombay  was  invulnerable  to  plague ;  besides,  nearly 
everything  concerning  plague  had  been  forgotten.  By  many  it  was 
considered  an  extinct  disease  so  far  as  modern  times  were  concerned, 
and  at  the  most  could  only  prevail  to  a  limited  extent  among  filthy 
and  uncivilised  people.  Its  diagnosis,  its  connection  with  rats,  and  its 
modes  of  extension  needed  all  to  be  learnt  afresh.  Cholera  was  the 
epidemic  disease  of  India,  and  the  infection  of  plague,  an  unknown 
disease,  was  largely  judged  and  measured  by  what  was  known  of  cholera. 
The  possibility  of  plague  infection  being  spread  at  times  by  merchandise 
and  other  agents,  besides  sick  persons,  was  discarded  as  antiquated  and 


CH.  Ill]  Plague  in  Bombay  67 

obsolete.     It  was  forgotten  that  plague  itself  was  antiquated,  and  that 

our  predecessors  with  much  experience  of  the  disease  may  have  correctly 

observed  many  things  connected  with  it.     Plague  had  been  absent  from 

Bombay  since   1702,  or  a  period  of  194  years.     These  long  intervals 

seem  peculiar  to  the  epidemiology  of  plague.     Between  the  epidemic 

in  London  in   1348  and  that  of  1499,  a  period  of  150  years  elapsed. 

An  interval  of  70  years  occurred  between  the  epidemic  of  1720  and  the 

previous  great  epidemic  in  Marseilles.     Moscow  was  attacked  in  1771, 

after  a  period  of  immunity  of  150  years,  and  Malta  when  attacked  in 

1813  had  been  free  from  an  epidemic  of  plague  for  137  years. 

Though  it  is  now  evident  that  plague  must  have  existed  as  early  as 

March,  1896,  in  Bombay,  the  first  cases  noticed  appear  to  have  occurred 

near  the   docks  on  the  Port  Trust  Estates  in  the  Mandvi  district  in 

August,   1896,  among    Moltanies    who    had  dealings   with   China  and 

among  the  Lohannas  and  Banias  of  the  same  district.     The  cases  were 

mistaken  for  diphtheria  and  fever.     At  this  time  the  mortality  in  the 

Mandvi  district  was  unusually  high,  but  it  was  attributed  to  remittent 

fever  and  lung  affections.     The  rats  were  also  dying  in  numbers,  but  no 

particular  importance  was  attached  to  this  phenomenon  then.    It  was  not 

until  the  23rd  of  September,  1896,  when  Dr  A.  G.  Viegas  drew  attention 

to  the  disease  being  probably  plague,  that  public  anxiety  was  aroused. 

The  diagnosis  of  plague  was  bacteriologically  confirmed  by  W.  Haffkine, 

the  Government  Bacteriologist,  on  October  loth.     After  the  first  alarm 

there   was  a  reaction  and  opinions  fluctuated  from  day  to  day  as  to 

the  nature  of  the  disease,  now  being  pessimistic  and  now  optimistic, 

according    to   the   number   of  deaths.     The  majority  of  citizens  were, 

however,  disinclined  to  believe  in  the  possibility  of  plague. 
Commence-  .  , 

ment  charac-      The  mildness  of  the  disease  and  its  slow  progress  led  to 

mudness^and      ^^^  being  called  glandular  fever,  or  bilious  fever,  or  indeed 

slow  exten-         anything  but  plague.    Haff kine's  report,  however,  dispelled 

illusions,  at  least  on  the  part  of  the  thinking  public. 

For  the  first  month  or  so  after  the  discovery  it  was  more  or  less 

limited  to  the  Mandvi  district,  and  then  it  commenced  to  spread.     Rats 

were  noticed  to  be  dying  in  other  quarters  of  the  town  than  the  Mandvi 

district,  and  wherever  this  happened  cases  of  plague  began  to  appear. 

The  Health  Department  set  vigorously  to  work  to  cleanse  and  disinfect 

the    infected    areas    and    houses,  and  to  segregate  the  sick.     But  the 

population    to   be   dealt   with    was   a   peculiar   one.      Oriental    in   its 

thoughts   and   habits,  superstitious   and   fanatical,  it  was  particularly 

sensitive  and  antagonistic  to  innovation  of  any  kind.     It  was  used  to 

5—2 


68  Histonj  and  Disfribfttiou  of  Plague        [part  i 

small  and  short-lived  epidemics  of  cholera,  and  knew  the  measures 
taken  for  that  disease,  and  it  was  persuaded  that  plague,  if  it  existed, 
would  be  equally  short-lived.     At  first  the  preventive  measures  were 

endured  with  grumblings,  but  as  the  disease  continued, 
the'adopwon  =^"d  began  to  look  more  serious,  the  policy  adopted,  western 
of  preventive  j,^  j^g  conception,  suited  neither  Hindu  nor  Mahommedan. 
measures.  .  .      „     ,.  r%        \      j-j 

Hostility  and  ill-feeling  were  soon  apparent,     reople  did 

not  and  would  not  understand  that  the  disease  was  infectious.  One 
medical  man,  convinced  of  the  non-infectious  nature  of  the  disease, 
insisted  on  sleeping  in  the  ward  with  his  patients,  and  died  of  plague. 
Every  sanitary  measure  was  opposed.  Denunciations  and  protests  were 
soon  followed  by  active  demonstrations  of  ill-feeling  by  stoning  of  the 
officers  engaged  in  plague  work,  attacking  of  the  ambulances,  and  even 
storming  of  the  plague  hospital.  To  such  a  pitch  of  excitement  were 
the  rougher  classes  of  the  population  aroused,  that  there  were  good 
grounds  for  fearing  a  riot  and,  worse  than  a  riot,  there  were  threatenings 
of  an  exodus  of  the  whole  conservancy  staff  and  of  the  dock  and  mill 
hands,  and  possibly  of  the  police  themselves.  To  allay  this  state  of 
feeling  the  notification  authorising  compulsory  removal  to  hospital  was 
withdrawn  three  weeks  after  its  first  appearance.  This  was  on  the 
30th  of  October.  The  difficulties  which  beset  the  local  authority  in  its 
endeavour  to  stay  the  progress  of  the  disease  were  not  removed  by  this 
concession.  Popular  feeling,  mo\ed  by  wild  rumours,  the  offspring  of 
an  excited  imagination,  or  evil  design,  or  ignorance,  was  swayed  first 
in  one  direction,  then  in  another,  but  never  in  sympathy  with,  or  in 
support  of,  the  sanitary  measures  devised  to  check  the  disease.  And 
so  the  plague  continued  to  spread.  The  people  had  lost  confidence  in 
medical  treatment.  It  was  not  a  question  of  notification  of  the  sick  by 
medical  men,  but  of  finding  out  the  sick  and  dead,  and  cleansing  and 
disinfecting  the  house.  The  disease  spread  remarkably  slowly,  con- 
sidering the  conditions  which  it  met  with. 

During  October  and  November,  the  disease  seemed  to  be  stationary 

^  .as  regards  the  number  of  deaths  recorded,  but  there  was 

Progress  of  " 

the  disease  an  ominous  circumstance ;  it  was  infecting  new  districts, 
with  the  ^^^^  ^^   ^^^^  observed  as  a  curious  phenomenon  that  the 

migration  of  progression  of  the  disease  was  intimately  associated  with 
the  migration  of  rats.  It  was  not  the  localities  to  which 
people  were  fleeing  from  infected  districts  that  were  showing  grave 
infection,  but  those  to  which  the  rats  were  migrating.  Suddenly,  in 
the  beginning  of  December,  the  mortality  from  plague  and  from  general 


CH.  Ill]  Extension}  to  Bombay  Presidencn  69 

causes   rose    to    twice    the    height   it   had  attained  before.     Then  the 

epidemic  began  in  earnest,  the  mortality  rising  week  by 

first  Bombay       week  until  the  2nd  and  3rd  week  in  February.     By  this 

epidemic  in        time  the  crisis  was  reached,  and  there  was  a  gradual  but 

Feb.  1897.  .  .  .  ° 

fluctuating    fall    in    the    weekly    mortality    from    general 

causes  and  from  plague,  until  the  last  week  in  May,  when  it  descended 

to  the  same  level  as  in  October  and  November.     Once  the  epidemic  set 

in,  panic  seized  the  inhabitants,  and  there  was  a  general  exodus  from 

Bombay.     Homes  and  shops  were  closed,  and  the  inhabitants  sought 

safety  in  flight.     Rumour  exaggerated  the  ravages  committed  by  the 

plague,  and  it  was  only  when  nearly  half  the  population  had  fled  from 

the  city,  and  the  deaths  from  plague  showed  marked  signs  of  declining, 

that  the  panic  began  to  subside.    To  this  exodus  is  to  be  chiefly  ascribed 

the  infection  of  localities  outside  Bombay. 

In  consequence  of  the  spread  of  plague  beyond  the  city  the  Govern- 
ment of  Bombay  took  over  the  control  of  plague  operation  earl}-  in 
March,  not  only  for  the  city  but  for  the  whole  Presidency. 

Plague  committees  were  formed  for  every  large  centre  where  plague 
existed.  Hospitals  were  erected,  health  camps  established,  and  search 
parties  constituted.  With  this  organisation  a  vigorous  policy  of  segre- 
gation of  the  sick,  and  removal  of  the  healthy  from  infected  houses  and 
areas  to  health  camps,  was  carried  out.  It  is  difficult  to  gauge  the 
value  of  these  measures,  for  they  were  introduced  into  Bombay  after  the 
crisis  was  reached  and  the  epidemic  was  already  waning.  But,  like  the 
preventive  measures  carried  out  by  the  municipality,  there  can  be  no 
doubt  that  they  contributed  in  no  small  degree  in  limiting  the  ravages 
of  the  epidemic.  In  May  and  June  the  disease  was  distinctly  of  a 
milder  type,  and  hopes  were  entertained  that  not  only  the  worst  period 
had  passed  but  also  that  the  city  of  Bomba}^  would  soon  be  free.  These 
hopes  were  not  to  be  realised,  for  since  its  first  appearance  in  1896  plague 
has  never  left  Bombay.  Every  year  there  have  been  recrudescences, 
reaching  epidemic  proportions  in  January,  February,  March  and  April. 

Plague  soon  began  to  spread  beyond  Bombay,  both  by  land  and  by 

sea.     Poona  was  affected  in  December,  Karachee  in  the 

the  disease  to     same  month,  and  as  distant  parts  as  Suhkur  on  the  Indus 

tbe  Bombay        ^ot  long  after.     The  infection  was  carried  even  as  far  as 

Presidency  r^  ^  ^  ■  ■     ^  ^ 

and  to  other      Calcutta,  where  m  one  quarter  occupied  by  Bombay  mer- 

india^'^^^  "^       chants  the  rats  began  to  die,  and  there  were  a  few  cases 
of  plague,  but  the  stringent  measures  there  taken,  espe- 
cially against  the  rats  in  the  infected  area,  were  successful  in  preventing 
the  disease  gaining  a  lodgement  in    ISiH),  and  it  was  not  until  April, 


70  History  and  Disfribuffon  of  Plague        [part  i 

1898,  that  plague  gained  a  firm  hold  in  Calcutta,  apparently  by  fresh 
introduction  of  infection. 

Besides  these  important  centres  the  malady  spread  to  the  adjacent 
districts  of  the  Bombay  Presidency  and  its  Native  States,  where  it  pre- 
vailed from  January  to  June,  causing  a  large  mortality.  Each  new 
centre  of  infection  in  turn  ofave  rise  to  others,  so  that  in  the  middle  of 

1897,  although  owing  to  the  decline  of  the  epidemic  at  that  period  the 
deaths  from  plague  were  comparatively  few,  yet  there  were  many  centres 
where  the  disease  had  acquired  a  firm  hold. 

The  maps  taken  from  an  account  of  plague  administration  in  the 
Bombay  Presidency  from  September  1896  to  May  1897,  by  M.  E. 
Couchman,  I.C.S.,  show  the  diffusion  and  spread  of  the  disease  from 
Bombay  along  the  coasts  and  along  the  lines  of  railway  and  traffic  in 
the  interior  of  the  Presidency.  It  will  be  observed  how  many  places 
were  infected  by  June.  These  localities,  in  the  next  epidemic  of 
1897-98,  acted  as  fresh  centres  from  which  more  places  were  infected. 

The  diffusion  of  the  disease  was  slow  and  b}^  no  means  corre- 
siow diffusion  sponded  locally  with  the  flight  from  Bombay;  often  long 
of  the  plague,  intervals  elapsed  between  the  first  recognised  imported 
case  and  the  first  indigenous  case,  and  in  many  localities  imported  cases 
were  not  followed  by  indigenous  cases,  and  when  indigenous  cases 
occurred  some  considerable  time  usually  intervened  before  they  assumed 
epidemic  proportions.  This  slow  diffusion  is  one  of  the  most  constant 
characteristics  of  plague.  The  Great  Plague  of  London  took  six  months 
to  travel  from  St  Giles'  to  Stepney.  In  1830  plague  existed  eight 
months  at  Alexandria  before  passing  to  Damietta  and  Mansurah, 
though  traffic  was  quite  uninterrupted.  In  Bombay  the  plague 
remained  confined  to  the  dock  quarters  for  a  considerable  time  before 
it  spread  to  other  districts.  At  Poona  over  six  months  elapsed  before 
the  disease  established  itself  at  Kirkee  which  was  in  daily  communi- 
cation with  Poona,  and  only  separated  from  it  by  a  river  spanned  by 
a  bridge.  By  September  and  October  of  1897  there  was  a  general 
rise  in  plague  prevalence  in  the  Bombay  Presidency.  The  southern 
portion  of  the  Presidency,  which  had  remained  more  or  less  free 
during  the  first  epidemic,  became  extensively  infected,  and  by  June, 

1898,  the  deaths  in  the  second  epidemic  were  double  those  of  the  first. 
61,000'  deaths  from  plague  were  recorded  against  29,000  in  the  first 
period.     The  second  epidemic  was  not  only  twice  as  severe   as   the 

1  "  The  Bombay  Plague,  being  a  history  of  the  progress  of  the  Plague  in  the  Bombay 
Presidency  from  September  1896  to  June  1899."  CompileJ  under  the  orders  of  Government, 
by  Capt.  J.  K.  Condon,  1900,  Bombay. 


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MAP    OF    SIND    IN    BOMBAY    PRESIDENCY. 
Plague  cases  from  month  of  March  to  end  of  June,   1897. 


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CH.  Ill]  Extejision  to  otJier  Presidencies  71 

first,  but  it  also  established  a  wider  area  of  infection.     In  the  third 

epidemic  ending  Jiine,  1899,  the  deaths  reached  over  115,000.     In  the 

district  of  Dharwar  alone  there  were  in  the  course  of  eight 

epidemics  at       months   80,000  deaths   from   plague.      In   the   same  year 

Dharwar  Poona   suffered   from   its    third  epidemic,  which   was    the 

and  Poona.  ^ 

most  severe  of  all.     In  the  course  of  four  months,  during 

June,  July,  August  and  September,  it  lost  nearly  10,000  of  its  in- 
habitants, although  half  its  population  fled  panic-stricken  from  the  city 
at  the  commencement  of  the  epidemic.  The  normal  population  of  Poona 
was  61,000.  For  a  period  of  over  six  weeks  it  lost  over  1000  persons 
a  week  from  plague.  The  greatness  of  the  mortality  may  be  gathered 
from  the  fact  that  if  a  similar  mortality  had  prevailed  in  London,  the 
metropolis  would  have  lost  over  10,000  persons  a  day. 

Fugitives  from  Bombay  and  the  Bombay  Presidency  were  not  long 

in  carrying  infection  to  the  other  provinces  of  India,  and 
Extension  of  ,  .  "^      .  ,  . .  .  ^      .  . 

the  plague         this    notwithstanding   certain  precautionary   measures   oi 

to  other  inspection   taken   on  the  railways.     The   development   of 

Presidencies.  ^      .  _  .  •'.  ^ 

the  disease  in  these  new  localities  was  slow,  and  at  first 

it  appeared  as  if  the  disease  were  quite  within  control,  but  gradually, 
in  spite  of  every  endeavour  to  stay  its  progress,  it  has  spread  through- 
out the  Indian  Peninsula,  affecting  some  places  but  lightly,  inflicting 
terrible  ravages  in  others,  and  leaving  many  untouched. 

The  progress  of  the  plague  in  India  has  been  slow.  During  the 
first  three  years,  as  pointed  out  by  the  Indian  Plague  Commission,  the 
disease  was  not  able  to  extend  and  take  a  hold  of  the  country  in  such 
a  way  as  seriously  to  affect  the  ordinary  death  rate.  The  Commission- 
dealing  with  that  period  conclude  that  "  ^although  the  figures  of  plague 
mortality  when  taken  by  themselves  are  high,  it  is  evident  that  plague 
has  not  as  yet  been  able  to  make  itself  felt  as  one  of  the  most  important 
factors  that  influence  the  total  mortality  of  India."  It  is  evident  that 
this  stage  is  past,  and  that  the  plague  is  now  a  very  important  factor  in 
the  Indian  mortality. 

Each  year  the  area  of  its  activity  widens ;  each  recurring  epidemic 

seizes  on  new  districts  besides  maintaining  its  hold  on  the 
Gradually  i      r     •    i  i 

increasing  old,  and  now  at  the  end  of  eight  years  the  annual  mortality 

ftom^he^  from  plague  in  India  has  risen  from  less  than  30,000  in  the 

plague  in  first  year  of  its  prevalence  to  little  less  than  a  million 

per  annum  in  1908.     This  represents  nearly  one-sixth  of 

the  annual  mortality  of  India. 

'   Report  of  the  Iiidimi  I'liujue  Coiiiiiiissioit,  Vol.  v.  chaji.  ii.  p.  50. 


72 


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CH.  Ill] 


Plague  Mortality  lit  India 

Number  of  Deaths. 


1000000 


900000 


800000 


700000 


6  50000 


400000 


250000 


200000 


150000 


TOTALS 


SEP. 
1896 

TO  END 
or  18971 


1898      1899 


JAN. 
1902  i    1903     TO  cwo 

OF  APRIL 

1904 


->^ 


73 


74  History  and  Distribution  of  Plague        [part  i 

The  preceding  tabular  statement  gives  the  annual  recorded  deaths 
from  plague  in  India  since  1896.  The  number  of  deaths  is  large,  but 
probably  it  is  understated  by  20  to  25  "/V  But  taken  as  it  stands  the 
mortality  is  nothing  less  than  one  of  the  most  disastrous  calamities  for 
India.  Year  by  year  the  mortality  rises  and  there  is  no  sign  of  abate- 
ment. In  the  first  four  months  of  1904  there  were  over  half  a  million 
deaths. 

A  very  extraordinary  fact  brought  out  in  this  table  is  the  immunity 
of  Europeans  in  contrast  with  the  susceptibility  of  Indians,  even  allowing 
for  the  comparatively  small  number  of  Europeans  in  India. 

With  plague  epidemic  in  India  and  Southern  China  the  intimate 

commercial  relations  which  exist  between  their  infected 
Extension  of 

the  plague  ports  and  the  ports  of  other  countries  were  likely  to  favour 

and^cwna^to       ^^^  spread   of  the   disease,  and  as  a  matter  of  fact  the 

other  parts         history  of  the  proo-ress  of  the  plague  is  that  few  maritime 

oftheworld.  /.  \    ^  .  ^ .  ''  ,  „ 

countries  participating  m  the  rivalry  oi  the  commerce  oi 

the  East  have  not  been  more  or  less  exposed  to  plague  infection  by  the 

arrival  of  ships  from  infected  ports.     As  earl}-  as  September,  1896,  two 

cases  of  plague  were  discovered  at  the  London  Docks  in  a  vessel  that 

left   India   before    plague    became    epidemic    in    that    country.     This 

experience   of  plague-infected   vessels   coming  from  infected  ports  has 

happened   to   most    maritime    countries  within    the   past    eight  years. 

Fortunately,  whether  it  be  from  precautions  taken  at  the  port,  or  from 

conditions  in  the   port   unfavourable  to  the   lodgement   of  plague,  or 

from   the  rarity  with   which   ships  carry  infection    on   them,  or  from 

ships    being   generally    unfavourable    to    the    propagation    of    plague, 

the  majority  of  the  ports   subjected   to   the   risk   have  escaped.     But 

although  there  has  not  been  a  general  infection  of  the  ports,  yet  the 

infection  has  been  carried  to  many  parts  of  the  world.     They  include 

ports  in  Asia,  North  and  South  America,  Australia,  Africa,  and  Europe. 

It  is  a  distribution,  as  far  as  is  known,  dissimilar  to  that  of  any  former 

epidemic  of  plague,  its  main  feature  being  that  the  course  followed  is 

a  maritime  one,  which  is  most  readily  explained  by  the  change  in  trade 

routes  which  has  taken  place  since  the  former  great  epidemics  of  plague. 

The  distribution  is  shown  on  the  map.     It  is  a  wide  diffusion  so  far 

as  distance  is  concerned,  and  is  wider  in  this  respect  than 
of  plague  in  ^.hat  which  characterised  previous  pandemics,  for  it  has 
different  parts  reached  America,  Australia,  and  South  Africa,  none  of 
of  the  world.  i  •  i    ,  i  i  i  i      i     i  i 

which  have  been  ever  known  to  have  had  plague  imported 

into  them  before.     With  the  exception  of  Africa,  the  infection  appears 


COURSE   AND    DISTRIBUTION    OF 


7(.i 


/ 


^^ 


\v. 


HO  Moi'"""'  '"^sia  an/        " 


](>(»  ]40 


GO 


REFERENCES 
*"•  Localities  in  which  Plague  prevailed 

X  Localities  in  which  one  or  more  imported  cases  of  Plague  occurred 
^■i  Endemic  centres 


1H(I 


160 


140 


]-J0 


100 


m 


CO 


40 


DISTRIBUTK 


(1^  IKI( 


OH 


(i;i; 


f»H| 


^■ 


)  I 


-X. 


r 


r\^ 


\ 


<NI| 


(t*:l 


ilTUaiilT8I0 


CH.  Ill]  An  African  Endemic  Centre  75 

mainly  to  limit  itself  to  the  ports,  or  to  localities  near  these.  It  is  also 
to  be  noticed  that,  notwithstanding  the  extensive  sowing  of  the  seed  or 
germ  of  plague  which  has  taken  place,  there  has  hitherto  been  no 
disposition  for  the  disease  to  become  severely  epidemic  except  in  India, 
China,  the  Mauritius,  and  in  the  year  1900  in  Cape  Town.  How  long 
this  fortunate  condition  of  affairs  will  continue  it  is  impossible  to  say. 
Plague  is  slow  in  its  progress  and  development,  and  evidently  has 
difficulty  in  adapting  itself  to  new  conditions  ;  it  remains  not  infrequently 
for  years  in  a  more  or  less  quiescent  state,  and  then  bursts  out  in  a 
destructive  and  expanding  epidemic.  While,  therefore,  the  ports  of  a 
country  are  infected  or  liable  to  infection  from  communication  with 
infected  ports,  that  country  is  never  free  from  the  danger  of  suffering 
from  a  plague  epidemic  which  may  assume  large  proportions. 

A  point  of  great  interest  in  regard  to  the  distribution  of  plague  is 

^     .  the  discovery  in  1897  of  an  independent  plague  focus  in 

An  endemic  ....  i     o 

centre  in  the  district  of  Kissiba,  to  the  extreme  north-west  of  German 

Uganda.  ^^^^  Africa.     Enquiries   seem   to  point   to  the  fact  that 

plague  has  been  endemic  in  Uganda  for  many  years,  and  that,  for  the 
last  30  or  40  years,  it  has  prevailed  in  sporadic  or  epidemic  form  in  the 
provinces  of  Buddu,  Koki,  and  Nkole.  It  appears  that  about  1889,  at 
the  time  of  a  severe  epidemic  of  plague  in  Buddu  and  Koki,  the  disease 
was  introduced  into  the  district  of  Kissiba,  where  it  spread  rapidly,  and 
where  in  1897  it  was  definitely  proved  by  Dr  Zupitza  and  Professor 
Koch  to  be  plague. 


PAET  II. 

EPIDEMIOLOGY   OF   PLAGUE. 


/ 


,/ 


CHAPTER  IV. 

NATURE   OF    INFECTION. 


/ 


/  The  nature  of  the  infection  is  no  longer  a  matter  of  surmise.     The 

discover}^  of  the  plague  bacillus  with  its  well-marked  characteristics  and 

/  powers  of  inducing  the  disease  in  some  of  the  lower  animals,  especially 

'  rodents,  when  inoculated  into  them,  has  put  an  end  to  the  speculations 

as  to  the  nature  of  the  virus. 

Pestiferous  emanations  from  the  soil  contaminating  the  atmosphere 

have  always  been  a  favourite  explanation  of  the  source  of 
Earlier  views  "^    .  •        i        i  i      i      i 

on  the  nature     the  plague  virus,  the  nature  of  which  has  been  looked  upon 

0  in  ection.        ^^  consisting  of  some  venomous  vapour  or  gas.     Boghurst 

in  his  Loimographica  on  the  Plague  of  London  of  1665  records  the 

general  opinion,  not  only  of  his  contemporaries  but  also  of  the  medical 

men  of  many  previous  centuries,  when  he  says :  "  My  opinion  falls  in 

t     wholly  with  those  who  make  the  earth  the  seminaiy  and  seed  plotts 

of  these  venomous  vapours  and  pestiferous  effluvia  which  vitiate  and 

corrupt  the  air  and  consequently  induce  the  pestilence'." 

This  opinion  was  not,  however,  held  by  all.     There  was  another 

school  which  suspected  that  the  infective  agent  of  plague  was  a  living 

entity  and  that  it  was  conveyed  from  person  to  person  by  contagion. 

Athanasius  Kircher  is  an  exponent  of  this  view.     In  1658  he  writes'-: 

'  Tnin-fuctions  of  the  Epidemiological  Society  of  London,  Vol.  xiii.  1893-94.  "Loimo- 
graphica. An  account  of  the  Great  Plague  of  London  in  the  year  1665  by  William 
Boghurst,  Apothecary."     Edited  by  Joseph  Frank  Payne,   M.D. 

2  Athanasii  Kirclieri,  E.  S.  J.,  Scrutiniitiu  Physico-Medicum  Contagiosae  Lnin,  quae 
Pest  in  dicitur.     Rome,  1658. 


CH.  iv]  Theory  of  Contagion  77 

"  Plague  is  in  most  cases  a  living  being  ;  for  the  sick  man  harassed  by 
pestiferous  virulence  soon  contracts  a  marvellous  putrefaction  which  we 
have  shown  to  be  most  apt  to  create  worms.  Now  these  worms,  pro- 
pagators of  the  plague,  are  so  small,  so  light,  so  subtile,  that  they  elude 
any  grasp  of  perception  and  can  only  be  seen  under  the  most  powerful 
microscope.  You  might  call  them  atoms,  but  they  spring  up  in  such 
numbers  that  they  cannot  be  counted ;  these  worms  when  they  have 
been  conceived  and  generated  from  the  putrefaction  are  easily  forced 
out  through  all  the  passages  and  pores  of  the  body,  and  since  they  are 
moved  by  the  slightest  movement  of  the  air,  just  like  so  many  sunbeams, 
are  diffused  here  and  everywhere  in  such  a  way  that  whatsoever  they 
run  across,  they  at  once  adhere  to  most  tenaciously,  insinuating  them- 
selves deeply  right  down  to  the  bottom  of  the  pores... Now  all  things 
are  liable  to  catch  this  pestiferous  brood,  linen,  cloths,  clothes,  skins, 
carpets,  feathers,  bedsteads,  ottomans,  tables,  articles  of  every  sort  even 
to  spoons,  knives,  table-tops,  cups,  belts,  &c.  For  when  this  outburst 
of  worms  or  worm  sprouting,  even  at  the  smallest  breath  of  air  (which 
can  happen  either  while  the  sick  man  upon  his  bed  tossing  himself  now 
on  this  side  and  now  on  that,  throws  the  clothes  and  coverlets  now  here 
now  there;  or  while  the  nurses  attending  on  the  sick  man  make  the  bed 
and  arrange  its  coverings  that  have  been  cast  off,  or  place,  or  raise,  or 
turn  in  any  way  the  patient  for  the  requirements  of  nature  or  the 
working  of  the  medicine),  get  blown  abroad,  and  a  virulent  brood  just 
like  atoms  or  particles  moved  by  a  breath  of  wind  diffuses  itself  like 
smoke  in  all  directions,  it  needs  must  be  that  all  things  are  infected  to 
which  it  adheres." 

On  this  or  a  somewhat  similar  hypothesis  did  the  contagionists 
explain  the  infectiveness  of  plague  until  the  Hongkong  epidemic  of 
1894,  when  Kitasato  and  Yersin  discovered  in  the  buboes  and  in  the 
blood  of  plague  patients  the  bacillus  of  plague.  After  reading  Kircher's 
description  one  is  left  in  doubt  as  to  whether  he  and  the  physicians  of 
his  time  did  not  actually  see  the  plague  microbe.  If  we  except  the 
exaggerated  facility  with  which  the  worms  he  speaks  of  as  being  visible 
under  the  most  powerful  microscope  leave  the  body  and  diffuse  them- 
selves in  the  air,  the  notions  as  to  the  nature  of  the  infection  and  its 
portability  are  not  unlike  those  of  the  present  day. 

In  1894,  on  the  outbreak  of  plague  at  Hongkong,  a  Japanese  com- 
mission of  which  Dr  Kitasato  was  the  Chief  was  despatched  to  Hongkong 
and  in  a  short  time  the  discovery  was  made  that  in  the  blood,  internal 
organs,  and  affected  glands  of  the  body  a  micro-organism  was  to  be 


78  Epidemiology  of  Plague  [part  ii 

found  in  all  cases  of  plague.     Later  Dr  Yersin  independently  made  a 

like  discovery.     The  bacillus  thus  associated  with  plague 

the  plague         ^'■^^  been   proved   to  be  the  causal   agent  of  the  disease. 

baciUus  and       Jt,  is  alwavs  found  in  the  buboes  and  affected  glands  of 

the  evidence  '  •        i       i  ■       i  , 

as  to  its  well-marked  cases  oi  plague,  in  the  blood  and  tissues  of 

relationship  *^^  septicaemic  variety  of  plague,  and  in  the  lungs  and 
sputum  of  pneumonic  plague,  and  this  is  the  case  wherever 
plague  occurs,  whether  in  China,  India,  Africa,  Australia,  America  or 
Europe.  Moreover  if  the  bacillus  is  isolated  from  a  plague  case  and  a 
pure  culture  groAvn  on  ordinary  nutrient  media,  the  disease  can  be 
produced  in  some  of  the  lower  animals  which  are  susceptible,  by  inocula- 
tion, and  from  the  tissues  of  these  animals  the  microbe  can  be  again 
recovered  in  pure  cultures.  Even  more  convincing  than  this  experimental 
evidence  is  the  accidental  production  of  the  disease  in  man  in  some  of  the 
bacteriological  laboratories  of  Europe  where  no  plague  existed  other 
than  that  artificially  produced  in  animals  in  the  laboratory  by  inoculation 
with  cultures  of  the  plague  microbe.  These  cultures  were  in  every  case 
descendants  through  many  generations  of  cultures  of  original  microbes 
obtained  from  plague  cases  in  India  or  elsewhere,  and  brought  in  culture 
tubes  to  the  locality  in  which  the  outbreak  occurred.  There  has  never 
been  any  doubt  as  to  the  plague  in  the  laboratories  being  caused  from 
any  other  source  than  the  cultures,  and  the  cases  have  occurred  when 
no  plague  existed  in  Europe. 

There  have  unfortunately  been  three  occurrences  of  this  kind.  The 
first  was  that  which  happened  in  Vienna  when  in  October,  1898,  more 
than  a  year  after  the  return  of  the  Austrian  Plague  Commission  from 
Bombay,  the  attendant  of  the  Pathological  Institution  in  Vienna,  who 
was  acting  as  assistant  to  Albrecht  and  Ghon  and  had  charge  of  the 
animals  experimented  on,  fell  ill  wath  pneumonia  which  proved  on 
examination  of  the  sputum  to  be  plague  pneumonia.  He  died  on  the 
fourth  day  of  illness  from  well-marked  plague.  Dr  Mueller  and  two 
nurses  who  attended  the  patient  were  also  attacked  with  pneumonic 
plague.  One  nurse  recovered,  but  Dr  Mueller  died  on  the  third  day  of 
illness  and  the  nurse  a  day  or  two  later.  Prompt  measures  were  taken 
to  prevent  the  disease  from  spreading  and  no  other  case  occurred  in 
Vienna  then  or  since. 

The  second  occurred  in  June,  1908,  when  Dr  Milner  Sachs,  who  was 
studying  bacteriology  in  Berlin,  infected  himself  while  injecting  a  rat 
with  a  culture  of  the  bacillus  of  plague.  He  contracted  plague,  it  is 
thought,  by  inhaling  particles  which  were  ejected  from  the  syringe  in 


CH.  iv]  Characteristics  of  the  Bacillus  79 

a  spray.  He  suffered  from  the  pneumonic  form.  He  fell  ill  on  June 
2nd  and  died  on  June  5th,  although  he  received  injections  of  Roux 
Yersin's  serum.  A  hospital  attendant  Marggraf  who  nursed  Dr  Sachs 
was  also  attacked  with  pneumonic  plague,  but  he  was  treated  ener- 
getically with  Yersin's  serum  at  an  early  stage  of  his  illness  and 
recovered.  The  precautions  taken  to  prevent  spread  of  the  disease  were 
successful.  They  consisted  in  isolation  of  the  patients  and  of  those  who 
had  come  in  contact  with  them,  and  burning  the  personal  effects  and 
any  suspected  furniture  and  goods. 

The  third  accident  was  in  January,  1904,  which  resulted  in  the  death 
of  the  Director  of  the  Laboratory  of  the  Imperial  Institute  of  Experi- 
mental Medicine  at  St  Petersburg,  who  contracted  plague  whilst  engaged 
in  experiments  with  plague  cultures.  Two  others  in  the  laboratory  also 
contracted  plague  and  died  from  the  same  cause.  All  were  treated  with 
plague  serum,  but  without  success. 

It  is  curious  that  all  the  cases  of  plague  contracted  in  the  laboratory 
and  when  dealing  with  animals  have  been  of  the  pneumonic  type. 

The  specificity  of  the  plague  bacillus  is  still  further  evidenced  by  the 
appearance  of  specific  protective  substances  in  the  blood  of  individuals 
convalescent  from  plague  and  in  the  production  of  these  specific  pro- 
tectives  in  the  blood  of  experimental  animals  treated  with  plague  bacilli, 
also  by  the  protection  afforded  by  inoculation  with  killed  plague  bacilli 
against  a  later  natural  infection. 

Much  was  done  in  studying  the  morphological  and  cultural  charac- 
teristics of  the  plague  bacillus  and  in  investigating  the 
logical  and         behaviour  of  the  micro-organism  under  known  conditions, 

staining  before  the  full  evidence  was  obtained  which   established 

character- 
istics of  that  the  bacillus  was  the  causal  agent  of  the  disease.     It 

bacUiuf"*         will  now  be  necessary  to  enter  into  the  results  of  these 

researches.       The    plague    bacillus    belongs    to    the    same 

cocco-bacillus  group   of  Haemorrhagic   Septicaemias,  such   as   chicken 

cholera  and  rabbit  septicaemia,  all  of  which  at  some  period  of  their 

existence  show  when  stained  a  bipolar  appearance.     The  typical  plague 

bacillus  is  a  short  thick  rod  rounded  at  its  extremities  and  more  or  less 

ovoid  in  form.    It  measures  from  '8  mm.  to  2  mm.  in  length  and  is  usually 

from  '4  mm.  to  "8  mm.  in  breadth.     It  is  more  constant  in  breadth  than 

in  length,  though  it  varies  in  breadth  more  than  other  bacilli.    It  varies 

considerably  in  shape  and  size,  so  that  in  a  microscopical  specimen, 

in    addition   to    the   typical  bacilli,   very    diverse   forms   may  be  seen, 

including  long  and   slender  bacilli   together  with  boat-shaped,  dumb- 


80 


Epldeniioloffn  of  Plague 


[part  II 


<<#4- 


4     Mt  * 


t 


^ 


^▼^ 


'•*J? 


i 


Plague  bacilli  in  contents  of  Bubo. 


mm 


Plague  bacilli  in  Sputum. 


CH.  iv]  Cultural  Characters  of  Bacillus  81 

bell  and  spherical  micro-organisms  resembling  cocci  and  diplococci  in 
their  appearance. 

This  pleomorphism  may  give  rise  to  difficulty  of  recognition  when 
plague  appears  in  a  locality  for  the  first  time  and  when  the  decision  of 
the  disease  has  to  rest  on  a  single  case.  Cultures  however  will  solve 
the  difficulty  if  the  stalactite  test  be  applied.  For  a  time  the  variation 
in  form  was  mistaken  for  contaminations  and  attributed  to  the  presence 
of  bacilli  unconnected  with  plague. 

The  bacillus  is  non-motile,  the  only  motion  being  Brownian  and  not 
that  of  translation ;  one  or  two  terminal  flagella  have  been  observed  and 
described,  but  they  have  been  seen  only  by  a  few.  No  spores  have 
hitherto  been  discovered. 

The  bacillus  is  easily  stained  by  aqueous  solutions  of  methyl  blue, 
gentian  violet,  fuchsin,  or  any  of  the  ordinary  basic  dyes,  but  is  not 
stained  by  Gram's  method  unless  a  weakened  spirit  solution  of  50  °/o 
is  used  instead  of  absolute  alcohol  for  the  decoloration  process.  The 
bacillus  is  stained  usually  more  deeply  at  the  extremities  than  at  the 
centre  and  thereby  acquires  a  very  characteristic  bipolar  staining.  This 
bipolar  staining  is  more  marked  in  microbes  taken  from  the  tissues 
direct  than  from  cultures,  also  in  the  ovoid  more  than  in  the  longer 
variety  of  bacillus.  In  some  cases  the  unstained  portion  is  not  in  the 
centre  but  at  the  side  or  end  of  the  bacillus,  and  in  other  cases  the  ends 
are  not  stained.  The  bipolar  staining  is  well  brought  out  by  over- 
staining  in  carbol  fuchsin  for  four  or  five  minutes  and  then  decolorising 
with  absolute  alcohol,  or  b}'  treating  with  acetic  acid  and  then  with 
carbol  fuchsin.  The  bipolar  staining  is  by  no  means  constant  in  every 
bacillus,  though  in  a  plague  specimen  it  is  generally  the  predominant 
feature.  In  some  smear  preparations  from  infected  tissues  nearly  all 
the  bacilli  show  the  bipolar  staining ;  in  others  only  a  small  proportion 
exhibit  this  characteristic,  and  occasionally  no  bipolar  staining  is  to  be 
observed.  In  most  specimens  some  of  the  bacilli  show  a  distinct  but 
unstained  capsule,  giving  the  appearance  of  the  bacillus  being" embedded 
in  a  viscous  matrix.  In  preparations  from  buboes  and  the  haemorrhagic 
effusions  around  them  the  arrangement  is  generally  a  few  single  micro- 
organisms intermixed  with  a  large  proportion  of  bacilli  in  pairs,  pre- 
senting a  diplococcal  or  diplobac-illar  appearance ;  and  not  infre(juently 
several  pairs  are  found  together  in  shorter  or  longer  chains  and  having 
the  appearance  of  streptobacilli  or  streptococci. 

Spherical,  torula-like,  and  disc  forms  may  be  found  in  old  buboes 
durin"'    life    and    in   affected   tissues    after  death.     These   swollen   and 


82  Epidemiolouji  of  Plague  [part  n 

irregularly  shaped  bacteria  do  not  stain  well,  and  often  only  a  faint 
outline  is  to  be  seen. 

In  the  living  plague  patient  the  bacilli  are  generally  very  abundant 
in  smear  specimens  of  the  contents  of  the  buboes  and  in  the  sangui- 
nolent  effusion  around  them,  crowds  being  seen  in  the  microscopic  field ; 
they  are  not  infrequently  to  be  seen  in  the  interior  of  the  white  blood 
corpuscles.  But  while  the  usual  characteristic  is  the  multitude  of 
bacilli  in  buboes,  there  are  occasions  when  they  are  few  in  number,  and 
they  are  only  detected  by  inoculating  the  material  from  the  affected 
gland  into  a  culture  medium.  Plague  bacilli  are  very  numerous  in 
the  sputum  of  pneumonic  cases,  which  at  times  literally  teems  with 
them.  They  are  also  to  be  seen  in  the  blood  of  septicaemic  cases  and 
in  the  contents  of  vesicles  and  pustules  that  sometimes  appear  on  the 
skin.  They  can  be  cultured  from  the  blood  and  urine  of  living  patients 
suffering  from  the  septicaemic  form. 

In  dead  bodies  the  bacilli  are  found  in  the  affected  buboes  and 
generally  in  the  spleen,  liver,  lungs,  bone  marrow,  bile,  urine,  peritoneal 
fluid,  and  fluid  of  the  brain.  It  is  this  universality  of  the  plague  bacillus 
which  is  the  danger  attached  to  corpses  and  which  renders  it  imperative 
that  special  precautions  shall  be  taken  immediately  death  occurs  to 
prevent  the  spread  of  the  infection.  In  septicaemic  cases  the  risk  is 
always  pronounced,  but  even  in  the  bubonic  form  the  bacilli  very 
frequently  gain  an  entrance  into  the  blood  stream  some  time  before 
death  and  become  disseminated  in  the  tissues  and  in  the  excretions,  so 
that  any  dribbling  or  escape  of  fluid  from  the  body  which  frequently 
takes  place  will  soil  the  bedding  and  the  floor. 

The  micro-organism  of  plague  is  distinctly  aerobic ;  it  grows  easily 
Cult    ai  ^^^  ordinary  culture  media  such  as  gelatin,  agar  agar,  broth, 

character-  blood  serum  and  glycerine  agar ;  it  grows  also  in  milk  and 

scantily  on  potatoes.  In  isolating  the  bacillus  for  diagno- 
stic })urposes  from  the  living  or  dead  body  the  temperature  at  which 
the  culture  medium  is  maintained  is  important.  Blood  heat  is  not 
favourable  to  the  growth  of  the  plague  bacillus,  and  if  there  are  other 
bacilli  present,  such  as  the  bacillus  coli  communis,  streptococcus  pyogenes, 
or  the  pneumococcus,  these  will  gi-ow  while  the  plague  bacillus  will  be 
inhibited.  Mistakes  may  thus  easily  arise,  and  the  pneumococcus  alone 
or  some  other  microbe  be  found  in  a  case  which  is  really  plague.  Plague 
bacilli  grow  best  at  a  temperature  considerably  below  blood  heat,  the 
most  favourable  being  from  25'  C.  to  30'  C.  The  first  cultures 
from  the  body  are  always  slower  in  growth  than  sub-cultures.     Both 


CH.  ivj  Involution  Forms  of  Bacillus  83 

agar  and  gelatine  plates  are  used  in  suspected  cases  of  plague.  The 
growth  on  most  of  the  media  possesses  no  distinctive  features  peculiar 
to  plague  other  than  those  which  are  obtained  on  gelatine,  agar  agar, 
and  in  bouillon.  On  blood  serum  it  appears  in  24  to  48  hours  as  a  moist 
cream-coloured  or  yellowish  growth.  On  gelatine  it  develops  in  the  form 
of  minute,  translucent,  and  raised  colonies  in  the  course  of  48  to  72 
hours,  and  which  have  a  dew-drop  appearance ;  it  may  even  take  as  long 
as  four  or  five  days  for  the  colonies  to  become  visible ;  later  the  colonies 
become  denser  in  the  centre,  of  a  greyish-white  colour  and  with  crenate 
margins.  The  colonies  differ  in  their  rate  and  extent  of  growth,  some 
remaining  stationar}^  in  size,  others  becoming  considerably  larger.  Under 
a  lower  power  of  the  microscope  they  have  at  first  the  appearance  of 
ground-glass,  and  later  a  dense  dark  granulated  centre  with  notched  edges 
more  or  less  transparent.  Deeper  colonies  in  gelatine  appear  at  first  as 
small,  rounded  refractive  granules,  white  in  reflected  light  and  brown  in 
transmitted  light.  In  stab  cultures  there  is,  in  addition  to  the  granular 
and  later  continuous  white  growth  along  the  tract  of  the  needle,  a  film 
on  the  surface  of  the  gelatine.  The  bacilli  do  not  liquefy  gelatine,  but 
they  liquefy  blood  clots. 

On  agar  agar  inoculated  with  plague  material  minute,  bright,  colour- 
less colonies  of  various  sizes  and  slightly  raised  develop  in  less  than 
48  hours  or  it  may  be  longer.  In  a  day  or  two  they  become  small, 
greyish-white  hemispheres  with  a  thin  iridescent  border.  Some  of  the 
colonies  remain  small,  but  others  continue  to  grow  in  diameter  and  some 
become  four  or  five  times  the  diameter  of  others.  They  are  generally 
discrete  at  first,  but  on  moist  agar  agar  the  colonies  coalesce  and  form 
white  and  opaque  patches.  If  touched  with  a  platinum  needle  the 
culture  is  found  to  be  of  a  sticky  and  viscid  nature,  adhering  in  strings 
to  the  needle,  and  allbwing  individual  colonies  being  moved  on  the 
surface  of  the  medium  without  disintegration. 

On  dry  agar  agar  slopes  when  the  material  has  been  evenly  spread 
on  the  surface,  minute  grejdsh-white  translucent  colonies  cover  the 
whole  surface  of  the  medium,  which  presents,  as  a  rule,  a  very  character- 
istic ground-glass  appearance  by  reflected  light  obtained  when  the 
culture  is  held  away  from  the  light  and  looked  at  from  the  back.  In 
a  few  days  there  will  be  seen  to  be  two  types  of  colonies,  one  of  which 
is  of  small  size,  more  or  less  translucent  and  constituting  the  majority, 
the  other  larger,  whiter,  more  opaque  in  ap}K'arance  and  gradually 
changing  to  a  slightly  yellowish-brown  colour  as  it  increases  in  size.  The 
latter  are  the  giant  colonies,  or  cannibal  colonies  described  by  Haflfkine. 

G— 2 


84 


Fjfuh miolofiij  of  Plaf/ne 


[part  II 


»     • 


•••• 


••      •  •#        • 


Early  stages  of  involution  forms 
of  plague  bacillus  iHaffkine). 


Intermediate  involution  forms  of 
plague  bacillus  (Haffkine). 


>9 


#     • 


Advanced  involution  forms  of  plague  bacillus  (Haffkinej. 


CH.  iv]  Involution  Forms  of  Bacillus  85 

Morphologically  the  two  types  contain  the  same  kind  of  bacilli ; 
possibly  there  are  more  longer  bacilli  in  the  giant  colonies  and  more 
involution  forms.  In  sub-cultures  the  colonies  appear  earlier  than  in 
cultures  from  infected  tissues :  they  have  a  greater  tendency  to  become 
confluent  and  to  form  a  cream-coloured  growth  with  thin  translucent 
and  iridescent  margins  possessing  a  pronounced  crenated  appearance. 
Sub-cultures  from  the  smaller  colonies  often  show  a  scantier  growth 
than  from  the  larger.  Young  colonies  when  examined  microscopically 
are  found  to  be  mainly  composed  of  short  bacilli  which  do  not  attain 
the  average  size  until  the  second  or  third  day.  Old  colonies,  especially 
the  giant  colonies,  may  contain  a  larger  proportion  of  longer  bacilli. 

The  bacilli  from  cultures  stain  much  more  easily  than  those  taken 
Involution  direct   from   infected  tissues,  and   there  is   not  the  same 

forms.  degree  of  bipolar  staining.     Hatfkine^  found  that  in  dry 

agar  agar  inoculated  with  plague  material  the  bacillus  may  undergo  as 
early  as  in  24  hours  certain  involution  changes,  so  that  in  addition  to 
the  short  typical  bacillus  the  culture  will  contain  many  other  forms. 
These  bacillary  forms  may  diverge  in  a  small  degree  only  from  the  type, 
or  they  may  become  so  different  as  to  cause  thera  to  have  no  resemblance 
to  the  elements  from  which  they  are  derived.  Some  are  only  enlarged 
in  length  and  breadth  but  do  not  lose  their  shape  nor  their  staining 
properties;  others  become  thickened,  swollen,  filamented  and  distorted  in 
form,  assuming  bizarre  figures  resembling  sausages,  pears,  spindles,  clubs, 
dumb-bells,  biscuits,  discs  and  other  irregular  globular  bodies.  They 
stain  only  very  slightly  and  irregularly  and  have  no  bipolar  staining. 
Vacuoles  are  sometimes  observed.  The  different  forms  which  they 
assume  are  to  be  seen  in  the  accompanying  photographs  and  diagram. 
These  involution  forms  may  develop  to  such  dimensions  as  to  be  twenty 
to  thirty  times  the  size  of  the  ordinary  young  forms.  In  the  same 
microscopical  specimen  there  will  be  seen  every  variety  of  shape  and 
size  ranging  fr<jm  the  smallest  to  the  largest.  Microbes  of  other  diseases 
vary  in  size,  but  they  are  usually  more  or  less  constant  in  their  diameter. 
It  is  not  so  with  the  plague  bacillus,  the  diameter  of  which  may  show 
very  great  differences  in  different  individuals  in  the  same  specimen. 
Similar  differences  are  displayed  in  their  capacity  of  staining:  some  stain 
well  and  imiformly,  others  show  the  bipolar  staining,  others  take  on 
only  a  pale  colouring  throughout  their  substance,  others  stain  at  the 
circumference  or  only  part  of  the  circumference,  and  others  with  vacuoles 
may  not  stain  at  all.  According  to  Haffkine  this  power  of  producing 
1  Brit.  Medical  Journal,  1897,  p.  1461. 


86  EpUlemiolofij/  of  PlcKjue  [part  ii 

involution  forms  may  be  lost  in  the  laboratory  after  sub-culture,  and 
appears  to  be  limited  to  recent  cultures  derived  from  plague  cases.  The 
involution  forms  may  not  appear  on  dry  agar  agar  for  three  or  more  days. 
According  to  Hankin  a  2|  to  '^h  "/o  of"  salt  added  to  the  agar  agar  will 
hasten  the-  ])r()ducti(jn  of  involution  forms.  Experiments  with  salted 
agar  agar  on  other  bactei'ia  do  nut  show  the  same  exaggerated  involu- 
tion forms  as  are  to  be  observed  witli  plague  bacilli.  Matzuschita^  has 
shown  that  salted  media  tend  to  produce  involution  forms  in  bacillus 
pyocyanus,  the  lactic  acid  bacillus,  anthrax  bacillus,  and  cholera  bacillus. 

The  involution  forms  appear  in  old  and  dry  cultures  of  agar  and  in 
cultures  on  potatoes.  They  do  not  appear  in  old  or  fresh  bouillon 
cultures.  Any  change  undergone  in  bouillon  is  that  of  disintegration. 
The  microbes  under  these  circumstances  appear  to  be  granular,  they 
however  retain  their  vitality.  Involution  forms  are  also  to  be  found 
occasionally  in  the  tissues  of  human  beings  who  have  died  of  plague, 
also  in  the  tissues  of  lower  animals  that  have  been  inoculated  with 
plague,  and  in  animals  that  have  died  of  plague  contracted  in  the 
natural  way  and  that  have  been  a  longer  time  in  dying  than  usual. 

The  involution  forms  are  apt  to  give  rise  to  uncertainty  and  disputes 
at  a  critical  stage  in  the  development  of  a  plague  epidemic,  and  a 
knowledge  of  them  accordingly  possesses  much  importance  from  a 
diagnostic  point  of  view.  In  the  early  period  of  the  outbreak  in  Cape 
Town  in  1901  a  number  of  the  rats  which  were  dying  showed  on 
examination  large  numbers  of  bacilli  which  were  larger  than  the 
ordinary  plague  bacillus  and  of  a  biscuit  shape ;  mixed  up  as  they  were 
in  many  instances  with  typical  plague  bacilli,  they  were  obviously 
involution  forms  of  the  micro-organism.  The  first  cultures  retained  the 
involution  character  and  were  fatal  to  pigeons  and  guinea-pigs,  and 
harmless  to  rabbits  and  a  baboon.  They  however  gave  when  cultivated 
in  broth  the  stalactite  growth  referred  to  later,  and  sidjsequently  they 
lost  the  involution  form  and  approximated  to  the  ordinary  type  of  the 
plague  bacillus. 

In  Ixiuillon,  cultures  of  the  plague  bacillus  resemble  those  of 
Characteristic     "streptococcus    pyogenes."      The    growth    begins    to   be 

growth  in  visible  on  the  second  day  in  the  form  of  fine  flocculent 

bouillon.  .  ,  " 

sticky    masses   adherent    to    the    sides    of  the    tube    and 

deposited  at  the  bottom  of  the  clear  liquid.     At  times  a  film  may  also 

form   on   the  surface.     Microscopically  examined   the  cultures  will  be 

found    to    contain    not    only  bacilli    single   and   in   pairs   of  a  coccoid 

'  Zeitschr.  fiir  Hygiene,  Vol.  xxxv.  1900. 


CH.  IY] 


Stalactite  Growth  in  Bouillon 


87 


character,  but  also  short  and  long  chains  of  bacilli  composed  of  five  or 
more  elements.  These  chains  have  often  the  appearance  of  streptococci, 
but  on  close  examination  with  a  high  power  will  be  found  to  consist  of 
coccoid  bacilli.  Bacilli  from  young  cultures  stain  well,  and  degenerative 
or  granular  forms  are  not  found  except  in  old  cultures.  To  Haffkine 
is  due  the  credit  of  demonstrating  that  the  bacilli  grow  in  a  very 
characteristic  manner  in  bouillon.  A  few  drops  of  oil  or  fat  in  the 
form  of  ghee\  cocoanut  oil,  olive  oil  or  linseed  oil,  added  to  the  bouillon 
facilitate  the  characteristic  formation,  but  they  are  not  necessary. 
Bouillon  so  treated  and  sterilised,  will  if  it  is  inoculated  afterwards 
with  the  plague  bacillus  and  kept  absolutely  still  and  free  from  any 
vibrations,  show^  scarcely  any  signs  of  change  during  the  first  two 
Formation  of  or  three  days.  Then  minute  flakes  appear  imderneath  the 
stalactites.  drops  of  oil  which  are  floating  on  the  surface  of  the 
medium.  These  flakes,  which  are  colonies  of  bacilli  attached  to  the 
drops  of  oil,  grow,  in  the  course  of  the  next  12  to  24  hours,  down  into 
the  depths  of  the  liquid  in  the  form  of  stalactites  which,  scanty  at 
first,  in  the  course  of  two  or  three  days  increase  in  number  and  size, 
and  fill  up  the  upper  half  or  sometimes  the  whole  volume  of  the 
bouillon. 


'  Ghee  is  a  preparation   of    clarified  butte 
ceremonial  purposes. 


Haffkine's  Stalactites. 

r  used  by  the  Hindus  as  a  food  and  for 


88  Epidemioloiiy  of  Plague  [part  ii 

If  the  Hask  is  shaken  the  stahictites  fall  in  snow-like  Hakes  to  the 
bottom.  The  fluid  again  becomes  clear,  and  if  the  culture  is  again 
kept  free  of  agitation  small  colonies  will  form  afresh  underneath  the  oil 
globules,  and  once  more  a  renewed  growth  of  stalactites  will  take  place 
similar  to  the  first,  but  slower  in  growth.  By  agitation  and  allowing 
the  flask  to  n-main  still  the  process  can  be  repeated,  and  a  series  of 
fresh  stalactite  sfrowths  can  be  obtained  sometimes  for  three  or  four 
months  until  the  nutritive  medium  is  exhausted.  The  bouillon  will 
then  no  longer  be  suitable  for  plague  bacilli,  which  will  remain  alive 
but  will  not  grow  in  it.  Sometimes  when  the  bouillon  is  inoculated 
direct  from  plague  tissues,  zoogieic  masses  of  bacilli  collect  at  the  sides 
of  the  flask  and  surface  of  the  liquid,  but  no  stalactites  are  formed, 
lender  these  conditions  if  the  flask  is  gently  shaken  the  stalactites 
usually  appear  in  24  to  36  hours. 

According  to  Kitasato'  there  is  a  bacillus  met  with  in  plague  cases 
_..      .  ,  which  has  not  all  the  marked  characters  mentioned,  but 

XUb3,S3itO  S 

plague  which  when  found  alone  resembles  in  many  respects  the 

diplococcus  pneumoniae.  It  is  the  one  to  which  Kitasato 
has  essentially  given  his  name.  Kitasato  in  describing  it  points  out 
that  Yersin's  bacillus  is  larger  than  his,  does  not  possess  the  distinctly 
diplococcus  appearance  of  the  latter,  is  very  polymorphic,  does  not 
possess  a  capsule,  is  not  motile,  and  is  decolorised  with  Gram's  method. 
Moreover  the  growth  of  Yersin's  bacillus  on  agar  is  extremely  luxuriant, 
and,  though  rather  slow  at  first,  continues  for  a  week  forming  creamy 
colonies  projecting  above  the  surface  of  the  media,  and  only  young 
colonies  are  small  and  transparent.  These  characteristics  contrast  with 
Kitasato's  bacillus,  the  colonies  of  which  are  extremely  delicate,  trans- 
parent, small  discs  which  attain  the  size  of  a  pin's  head  and  cease 
growing,  and  then  tend  to  disappear  on  the  fourth  day  of  incubation, 
presenting  in  all  respects  a  close  resemblance  to  the  growth  of 
diplococcus  pneumoniae.  Kitasato's  bacillus  curdles  milk  at  the  end 
of  the  second  day,  renders  bouillon  uniformly  turbid  at  first,  but 
subse(piently  forms  fine  flocculi  and  sedimentation  at  the  bottom  of  the 
test  tube.  This  bacillus  is  rod-like  in  shape,  rounded  at  both  ends 
and  stains  more  deeply  at  the  poles.  In  the  glands  many  of  them 
appear  like  diplococci,  though  there  is  a  considerable  number  of  the 
same  microbes  which,  staining  easily  in  the  middle  portion,  present 
distinctly  bacillary  forms.  In  the  lungs,  heart,  brain  and  spinal  cord 
they  may  present  an  appearance  like  streptococci.     This  bacillus  stains 

^  "Plague,"  by  Kitasato  and  Nakagawa,  Twentieth  Century  Practice  of  Medicine,  Vol.  xv. 


CH.  iv]  Vitality  of  the  Bacillus  89 

with  Gram's  method,  possesses  a  capsule  in  the  specimens  prepared 
from  the  blood  or  tissue  fluids  of  various  organs,  and  also  in  cultiva- 
tions in  solid  serum,  is  slightly  motile  and  is  much  more  constantly 
found  in  the  blood  during  illness  and  convalescence. 

It  is  to  be  noted,  however,  that  bacteriologists  to  whom  strains  of 
Kitasato's  bacillus  have  been  sent  have  not  found  all  these  marked 
differences,  and  have  come  to  the  conclusion  that  Kitasato's  and  Yersin's 
bacillus  is  the  same,  differing  only  in  unimportant  respects  as  regards 
morphology  and  cultural  characteristics  as  are  to  be  observed  in  other 
pathogenic  bacilli. 

Many  experiments  have  been  made  to  determine  the  power  which 
The  vitality  ^^®  plague  bacillus  possesses  of  maintaining  life  under 
of  the  plague  unfavourable  conditions.  The  result  of  these  is  to  show 
that  while  the  bacillus  is  very  sensitive  to  drying  com- 
bined with  high  temperature,  yet  when  it  is  protected  from  these, 
which  must  ordinarily  be  the  case  under  natural  conditions,  it  retains 
its  viability  for  long  periods. 

Experimenters  differ  in  the  results  which  they  have  obtained,  but 
the  practical  point  is  to  know  the  longest  period  that  the  bacillus 
survives  under  certain  conditions,  and  accordingly  most  importance  is 
to  be  attached  to  this,  which  should  always  be  taken  as  the  safer  guide. 

AbeP  found  that  plague  bacilli  will  live  in  sterilised,  distilled  and 
In  different  tap  water  for  20  days.  Kasanski  found  it  in  water  on  the 
media.  4f'^t\\  day,  Wuntz  and  Bourge  in  sea  water  after  47  days. 

Hankin  ascertained  that  plague  bacilli  added  to  grain  died  out  in  from 
6  to  13  days,  Gladin-  that  plague  bacilli  will  live  in  milk  for  over 
8  months,  and  on  food  such  as  raw  and  coagulated  albumen,  turnips, 
potatoes,  plums,  apples,  cucumbers,  and  black  bread  from  one  to  three 
weeks,  Stadler  that  the  bacilli  will  remain  alive  in  meat  pickled  for 
16  days,  Yokote^  that  buried  carcases  of  animals  dying  of  plague  retain 
the  bacillus  alive  for  30  days,  Batzaroff^  that  the  organs  of  plague 
animals,  dried  in  vacuum  for  38  days  at  the  temperature  of  the  room, 
still  contain  living  bacilli,  and  when  the  dried  pulverised  substance,  so 

^  Ccntralblatt  fiir  Bakteriolor/ic,  I'drasitenkunde  iind  Infektionxkrankheiten,  1897. 
Vol.  XXI.     Zur  Keuntnis  der  Pestbacillea.     Dr  Eudolph  Abel. 

-  Ihiil.,  1898.  Vol.  XXIV.  "  Die  Lebensfaliigkeit  der  Pestbacillea  luiter  verschiedeuen 
physikalischen  Bedingungeu."     G.  P.  Gladin. 

^  Ibid.,  1898.  Vol.  xxiii.  "  Ueber  die  Lebensdauer  der  Pestbacillea  in  dor  beenligten 
Tierleiche."     Dr  L.  Yokote. 

■*  Annales  de  VInstitut  Pasteur,  torn.  xiii.  p.  ,38.5.  "La  Pneumouie  pesteuse  experi- 
mentale."     Dr  Batzarotf. 


90  Epidemiology  of  Plague  [part  ii 

treated,  was  inserted  into  the  mucous  membrane  of  susceptible  animals 
it  caused  plague.  The  same  observer  noticed  that  the  virulence  of  the 
microbe  in  all)uniin()us  tissues  decreased  very  slowly.  Faeces  containing 
plague  bacilli  and  left  standing  at  the  ordinary  temperature  for  three 
days  infected  a  guinea-pig  with  plague.  Sputum  from  a  pneumonic 
case  of  plague  was  found  to  retain  its  virulence  on  the  10th  day. 

While  the  association  of  the  streptococcus  appears  to  exert  a 
stimulating  effect  on  the  virulence  of  the  plague  microbe,  it  has  been 
noticed  by  a  number  of  observers  that  the  presence  of  bacillus  coli 
communis,  the  bacillus  subtilis,  the  staphylococcus  and  micrococcus 
prodigiosus  appears  to  exercise  a  retarding  influence. 

A  gelatine  plate  with  virulent  plague  bacilli  upon  it,  which  was 
expo.sed  in  a  dark  and  damp  room,  and  on  which  saprophytic  organisms 
of  fungi  grew,  was  found  by  Simonds  to  have  lost  its  infective  properties 
in  two  days.  On  the  other  hand,  Gotschlich  found  the  bacillus  alive 
and  virulent  in  8|^  months  old  cultures  which  were  partially  drv  and 
mouldy. 

In  broth  culture  Haffkine  found  the  plague  bacillus  alive  after 
18  months.  Gabritschewsky  kept  the  bacillus  in  an  agar  culture  alive 
stored  in  a  cupboard  for  two  years,  also  in  the  pus  w^hich  was  taken 
from  an  infected  guinea-pig  and  sealed  in  a  tube.  Pure  cultures^  of 
the  plague  microbe  protected  from  drying  have  been  known  to  retain 
their  viability  for  four  years  if  protected  from  sunlight  and  kept  in  a 
cool  place.  Klein-  has  recently  reported  that  the  bacillus  obtained  from 
the  fatal  case  of  plague  in  the  London  Docks  in  1896  still  retains  a 
fair  degree  of  virulence  in  sub-cultures ;  such  retention  of  vitality  and 
virulence  in  .sub-cultures  has  to  be  distinguished  from  that  obtaining  in 
old  and  unrenewed  cultures. 

Even  under  intense  cold  the  bacilli   may  thrive :    thus  Kasansky^* 

showed    that    cultures    placed    outside    his    laboratory    at 
Effect  of  cold.  .  .     ^  ,       1  ■   ,  • 

Kasan  during  the  winter,  and  which  were  subjected   to 

temperatures  ranging  between  2°C.  and  —  31'' C.  below  zero  for  periods 

of  3,  4,  and  5^  months,  retained  their  viability  and  were  only  weakened 

in  their  virulence.     Similarly  at  St  Petersburg  bacilli  remained  alive 

at  temperatures  of  zero  and  —  20"  C. 

'  Centralbl.  f.  Bakt.  1901.  Vol.  xxix.  "  Ueber  die  Lebensdauer  von  Bacillus  pestis 
hominis  in  Reinkulturen."     N.  K.  Schultz. 

-  Medical  supplement  to  the  32n(l  Report  of  the  Local  Government  Board  for  1902-1903, 
p.  402. 

3  Centralbl.  f.  Bakt.  1899.  Vol.  xxv.  "Die  Einwirkung  der  Winterkiilte  auf  die  Pest- 
bacillen."     Dr  M.  W.  Kasansky. 


CH.  IV J  Vitality  of  the  Bacillus  91 

The  capacity  of  the  plague  microbe  to  survive  exposure  to  intense 

cold   is   much   g^reater  than   its  power  to   withstand  the 

Effect  of  heat.         ^-  ^  •  ,  ,       i  •  i  t  i 

enects  of  mtense  heat  whether  moist  or  dry.     in  regard 

to  the  effect  of  heat  on  the  plague  microbe  there  is  much  difference 
in  the  results  obtained  by  different  observers,  the  time  required  for 
destroying  the  vitality  of  the  microbe  not  being  constant  and  differing 
in  some  important  particulars.  The  difference  in  time  and  the  differing 
results  may  be  due  to  the  different  methods  employed,  and  to  the 
probability  that  in  some  of  the  experiments  the  vessel  containing  the 
plague  bacilli  was  not  wholly  submerged  and  subjected  to  the  tem- 
perature stated.  For  instance  in  some  experiments  a  temperature  of 
80°  C.  has  killed  the  bacillus  in  five  minutes,  in  others  it  has  required 
15  minutes.  Abel  observed  that  with  50°  C.  more  than  an  hour  was 
required  for  sterilising  cultures.  Toptschieff\  on  the  other  hand,  found 
that  from  two  to  four  hours  were  required  with  a  temperature  of  50°  C. 
to  destroy  the  vitality  of  the  bacillus.  Kitasato  killed  the  bacillus  in 
half-an-hour  with  a  temperature  of  60°  C.  Yersin  sterilised  cultures  of 
the  bacillus  by  maintaining  them  at  a  temperature  of  58°  C.  for  an 
hour,  but  Albrecht  and  Ghon  after  heating  cultures  for  an  hour  in  a 
water-bath  at  55°  C.  to  60°  C.  found  that  all  the  microbes  were  not 
destroyed  and  that  it  was  possible  with  the  microbes  thus  subjected  to 
these  temperatures  to  produce  plague  in  animals. 

According  to  Haffkine  after  a  quarter  of  an  hour's  exposure  to  a 
temperature  of  45°  C.  an  agar  or  bouillon  culture  of  plague  bacilli  is  no 
longer  cultivable ;  and  as  a  matter  of  routine  practice  the  plague 
prophylactic  is  sterilised  at  a  temperature  not  higher  than  55°  C. 
continued  for  only  15  minutes.  The  microbes  are  killed  at  once  when 
exposed  to  a  temperature  of  100°  C.  moist  heat,  and  this  is  the  tem- 
perature to  which  plague-infected  articles  should  be  exposed.  Dry 
heat  requires  a  higher  temperature  and  a  longer  exposure  of  the 
bacillus  to  be  destructive.  Dry  heat  will  destroy  the  vitality  of  the 
plague  bacillus,  as  shown  by  Gladin,  in  one  minute  at  a  temperature  of 
160°  C,  in  five  minutes  at  130°  to  140°  C,  and  in  20  minutes  at  a 
temperature  from  100°  to  110°  C.     The  effect  of  the  direct  rays  of  the 

sun    is    rapidly    injurious    to    the   vitality   of  the    plague 
Effect  of  sun.  .  t       tt         i  j     t    j-  1  ^u  ' 

microbe.      In    Hongkong   and    India,    where    the    sun    is 

strong,  experiments  by  Kitasato,  Wilm,  and  the  German  and  Indian 

Plague  Commissions  establish  the  fact  that  plague  bacilli  exposed  in 

1  Ibid.,  1898.      Vol.  xxiii.  p.  734.     "Beitrag  zum  Einfluss  der  Temperatur  auf  die 
Mikroben  der  Bubonenpest."     F.  J.  Toptschieff. 


92  Epidemiolofiji  of  Plague  [part  ii 

thin  layers  to  the  direct  rays  of  the  sun  have  their  vitality  destroyed  in 
the  course  of  a  few  hours ;  usually  one  hour  suffices,  but  it  depends  on 
the  thickness  of  the  layer.  The  devitalisation  of  the  microbe  takes 
longer  if  the  bacilli  are  protected  by  a  covering  or  by  the  interstices  of 
woollen  or  other  textile  fabrics. 

Agar  or  broth  cultures  of  plague  exposed  for  three  hours  to  direct 
sunlight  in  Bombay  grew  with  difficulty  when  transferred  to  new 
culture  media,  but  were  only  killed  after  exposure  for  the  whole  day. 

In  temperate  climates  the  effijct  of  direct  sunlight  is  slower  in  its 
action,  and  exposure  of  cultures  for  six  hours  by  Albrecht  and  Ohon 
had  no  injurious  action  on  the  microbes. 

The  bacilli  are  very  sensitive  to  rapid  desiccation ;  plague  bacilli  on 
cover- glasses  placed  in  a  desiccator  containing  sulphuric  acid  or  chloride 
of  calcium  are  destroyed  in  a  few  hours.  The  bacilli  are  more  sensitive 
to  drying  at  a  high  temperature  than  at  a  low  temperature ;  drying  at  a 
Effect  of  temperature  of  S5^  C.  will  according  to  Abel's  experiments 

drying.  j^-u  ^j^^  bacilli  in  two  to  three  days,  while  drying  at  16°  C. 

to  20^  C.  will  not  destroy  them  until  the  6th  and  9th  day,  and  on  one 
occasion  the  bacilli  remained  alive  till  the  14th  day. 

When  Kitasato  dried  the  contents  of  buboes  on  cover-glasses  and 
kept  them  at  a  temperature  of  28^  C.  to  30°  C.  the  vitality  of  the  bacilli 
was  destroyed  by  the  4th  day.  The  power  of  resistance  to  drying  was 
increased  w'hen  thread  or  small  pieces  of  material  were  impregnated 
with  plague  cultures  or  infectious  matter.  According  to  the  Indian 
Plague  Commission,  laboratory  experiments  under  the  ordinary  atmo- 
spheric conditions  of  Bombay  do  not  demonstrate  any  great  increase  of 
resistance  or  any  long  survival  of  the  microbe  when  exposed  to  darkness 
or  diffuse  sunlight. 

Cotton,  silk,  wool,  linen,  glass,  blotting-paper  and  gauze,  impregnated 
with  pure  cultures  of  the  plague  bacillus,  with  sputum  from  j)neumonic 
plague,  with  emulsion  of  plague  organs,  or  with  peritoneal  Huid  from  a 
plague-infected  guinea-pig,  were  found  by  the  German  Commission  to 
be  non-infective  in  eight  da3's,  i.e.  the  ])lague  bacilli  did  not  survive 
more  than  eight  days  in  these  materials  under  ordinary  atmospheric 
conditions.  Moisture  under  certain  circumstances  is  rapidly  injurious 
to  the  vitality  of  the  bacillus.  Ficker  observed  that  alternate  damping 
of  the  bacillus  during  the  process  of  drying  hastened  its  death.  By 
such  a  process  the  bacilli  were  killed  in  from  20  to  28  hours,  whereas 
by  drying  only  in  the  desiccator  they  lived  for  eight  or  nine  days. 

A  hot  and  moist  atmosphere  will  not  only  cause  the  death  of  the 


CH.  iv]  Varyhig  Virulence  of  the  Bacillus  93 

bacillus  but  will  destroy  its  structure.  The  writer  dried  and  fixed  a 
large  number  of  specimens  of  bacilli  on  cover-glasses  in  Hongkong  and 
kept  them  in  cardboard  boxes.  By  the  time  they  reached  England 
none  of  the  bacilli  would  stain  or  could  be  detected.  Their  bodies  had 
evidently  been  macerated,  disintegrated  and  destroyed  by  the  moisture 
of  the  air  to  which  they  had  been  subjected.  Experiments  on  silk,  wool, 
cotton,  cloth,  etc.  in  Europe  have  shown  that  the  bacillus  may  survive 
45,  56,  60,  and  76  days.  The  Indian  Plague  Commission  also  found  the 
plague  bacillus  to  survive  on  calico  for  a  period  of  70  days. 

Experiments  in  Sydney  by  Dr  Tidswell'  to  ascertain  the  extra 
corporeal  viability  of  the  plague  bacillus  on  various  sterilised  materials 
demonstrated  that  the  plague  bacilli  died  out  in  periods  varying  from 
less  than  one  day  to  three  weeks,  the  longest  being  when  the  culture 
was  mixed  with  dust,  cotton,  and  straw  respectively  and  slowly  dried. 

A  most  interesting  observation,  and  one  which  is  of  the  highest 
importance  in  its  bearing  on  the  possible  long  duration  of  the  survival 
of  plague  bacilli,  is  that  which  was  carried  out  by  Kitasato  in  Japan 
when  plague  was  imported  into  Kobe  in  1899.  It  was  suspected  that 
the  plague  had  been  introduced  by  a  ship  which  had  arrived  at  Kobe 
with  a  consignment  of  cotton  goods  from  Bombay :  among  these  cotton 
goods  were  some  dead  rats.  It  is  not  known  how  long  the  rats  had 
been  dead. 

Two  hundred  culture  tubes  were  inoculated  with  portions  of  the 
cotton  and  in  two  plague  bacilli  were  grown  and  isolated. 

The  virulence  of  the  plague  microbes  often  decreases  in  some 
Variation  in  cultures,  while  in  others  it  apparently  not  only  retains  its 
virulence.  virulence   but  increases   in   intensity.     The  cause  of  the 

variation  is  unexplained. 

Batzaroff'^  succeeded  in  increasing  the  virulence  of  a  broth  culture  of 
the  plague  bacilli,  which  had  lost  its  power  of  killing  a  rat  and  a  guinea- 
pig  even  in  large  doses,  by  depositing  a  portion  of  the  culture  in  the 
nostril  of  a  guinea-pig.  In  eight  days  the  guinea-pig  died  of  pneumonic 
i)lague.  Then,  by  inoculating  a  series  of  guinea-pigs  he  was  able  by 
the  third  or  fourth  transmission  to  raise  the  virulence  of  the  microbe  to 
the  degree  of  causing  death  in  three  days.  An  atmosphere  containing 
3  per  cent,  of  carbonic  acid  gas  and  97  per  cent,  of  ordinary  air  at  80 

1  Further  observations  on  the  mode  of  Infection.  By  Frank  Tidswell,  M.B.  Embodied 
in  the  Report  of  the  Board  of  Health  on  a  second  outbreak  of  Plague  at  Sydney,  1902. 
By  J.  Ashburton  Thompson,  M.D.,  President. 

■■'  Anilities  lie  I'liisiitnt  I'nsteitr,  1S99.      Tom.  xm. 


94  Epklemiolocin  of  Plague  [part  ii 

to  88'  F.,  also  an  admixture  of  14  jjor  oi-nt.  of  carbonic  acid  and  86  j)er 
cent,  of  ordinary  air  at  92'  F.,  were  found  by  Marsh^  to  enhance  the 
growth  and  the  multiplication  of  the  plague  bacillus,  and  that  under 
this  treatment  the  bacillus  increases  in  virulence  and  retains  its  vitality 
for  a  long  time.  From  these  experiments  it  is  concluded  that  probably 
the  vitiation  of  the  atmosphere,  which  is  produced  when  the  ventilation 
of  a  room  occupied  by  human  beings  is  inadequate,  is  capable  not  only  of 
stimulating  thi-  reproduction  of  the  jjlague  bacillus  but  also  of  increasing 
its  virulence.  Other  experiments  indicated  that  a  deficiency  in  the 
amount  of  oxygen  is  favourable  to  the  vitality  of  the  plague  bacillus. 
By  passage  through  one  species  of  animal  the  general  result  seems  to  be 
an  increase  of  virulence  for  that  species,  but  a  diminution  of  virulence 
for  other  species. 

Experiments  on  the  duration  of  the  vitality  and  virulence  of  the 
plague  microbe,  though  contradictory  in  some  respects,  may  be  taken  as 
indicating  that,  though  under  certain  laboratory  conditions  the  microbe 
is  very  sensitive  to  atmospheric  and  microbic  influences  when  the 
influence  of  sunlight  and  moderately  high  temperature  come  into  play, 
yet  under  other  conditions  of  darkness  and  low  temperature  it  displays 
a  prolonged  power  of  resistance  and  retention  of  virulence. 

When  cultures  or  infectious  material  in  the  dark  can  retain  their 
vitality  and  virulence  for  two  and  four  years,  it  is  not  beyond  the  bounds 
of  credibility  for  certain  infected  articles  under  favourable  conditions 
to  retain  their  infection  for  a  long  time,  and  that  some  of  the  older 
observations,  such  as  that  of  a  rope  used  for  letting  down  plague 
corpses  into  the  grave  retaining  infection  for  a  long  time  and  causing 
a  fresh  outbreak,  may  not  be  discarded  as  impossible. 

It  has  already  been  stated  that  the  inoculation  of  susceptible  animals 

with  the  plague  bacillus  obtained  from  pure  cultures  causes 

plague  ba-  certain  symptoms  ending  in  death,  and  that  the  bacillus 

ciuus  on  jg  ao^ain  recovered  in  pure  cultures  from  the  blood  and 

animals.  .        "  '■ 

internal  organs  of  the   affected  animal.     The   laboratory 

animals  experimented  on  have  been  generally  rats,  mice,  guinea-pigs 

and    rabbits.     Inoculation   of  any   of  these   with   the   plague   microbe 

causes  a  definite  illness  in  them,  followed  usually  by  death  in  a  few 

days. 

A  guinea-pig  inoculated  with  the  plague  microbe  or  with  a  portion 

of  the  bubo,  or  the  organs  of  a  plague  patient,  usually  becomes  drowsy 

and  disinclined  for  food  within  48  hours.     After  this  period  it  remains 

1  Report  of  the  Ind'uui  I'lniiiie  (Joininission.  Vol,  iii.  ji.  73,  also  Vol.  v.  .Vpp.  iii.  p.  480. 


CH.  rv]  Vari/ing  Effect  of  the  Bacillus  95 

huddled  up  in  its  cage  with  back  arched,  staring  coat  and  half-closed 
eyes,  unwilling  to  move  even  when  disturbed,  and  sometimes  breathing 
in  a  laboured  manner.  Towards  the  end  it  falls  on  its  side,  suffering 
at  intervals  from  tremors  or  convulsions,  and  dies  in  the  course  of  the 
fourth  or  fifth  day  after  inocidation. 

The  post-mortem  appearances  show  haemorrhagic  infiltration  with  a 
good  deal  of  effusion  at  the  seat  of  inoculation,  the  parts  being  oede- 
matous  for  some  distance  from  the  point  of  inoculation.  The  adjacent 
glands  are  congested  and  swollen,  having  a  sanguinolent  effusion  around 
them.  The  lungs  are  generally  normal,  but  they  may  show  pneumonic 
patches,  the  heart  is  congested,  the  blood  is  fluid  and  darker  in  colour 
than  usual,  the  liver  is  mottled  and  congested.  There  are  also  small 
petechial  haemorrhages  in  the  lungs,  heart,  spleen,  and  kidneys,  as  well 
as  in  the  pericardium,  peritoneum  and  parietal  pleura.  The  intestines 
are  not  generally  much  affected.  The  whole  appearance  is  one  of 
engorgement  with  dark  fluid  blood.  Plague  bacilli  are  to  be  found  in 
the  blood,  liver,  and  spleen,  and  may  at  times  be  found  also  in  the 
lungs  and  kidneys. 

Mice  and  rats  inoculated  usually  show  signs  of  illness  within  48  hours 
and  present  much  the  same  symptoms  as  those  described  as  occurring 
in  the  guinea-pig.  The  course  of  the  disease  is  as  a  rule  more  rapid, 
death  occurring  on  the  third  day.  The  post-mortem  appearances  are 
similar  to  those  found  in  the  guinea-pig. 

The  length  of  illness  may  vary  in  the  animals  inoculated,  but  death 
generally  occurs  in  mice  in  from  one  to  three  days,  in  rats  from  the 
second  to  the  fourth  day,  in  guinea-pigs  in  two  to  five  days,  and  in 
rabbits  in  from  four  to  seven  days.  A  chronic  form  of  plague  may  occur 
in  rats  and  guinea-pigs  in  which  the  animal  does  not  die,  or  dies  only 
after  several  weeks  or  longer,  and  then  often  in  an  emaciated  condition. 
In  this  form  the  affected  glands  are  usually  found  in  a  cheesy  condition. 
There  are  small  areas  of  necrotic  tissue  in  the  several  internal  organs, 
and  the  spleen  is  generally  much  enlarged.  Only  few  bacilli  are  to  be 
found,  but  the  tissues  containing  them,  if  administered  to  a  healthy  rat 
or  guinea-pig,  will  reproduce  the  disease. 


^ 


CHAPTER    V. 


THE    RELATIONSHIP   OF   EPIZOOTICS   TO    PLAGUE. 

The  results  obtained  by  the  experiments  on  laboratory  animals  were 
Rats  and  mice  ^^  greater  import  than  merely  affording  evidence  that  the 
susceptible  to  plague  microbe  causes  a  disease  in  them,  and  can  be  again 
plague  infec-  recovered  from  their  tissues.  They  proved  that  rats  and 
*^°°-  mice  were  susceptible   in  a  high   degree   to   the    plague 

microbe,  and  suggested  an  explanation  of  the  phenomenon  which  has 
been  observed  from  the  earliest  times,/and  which  has  often  accompanied 
an  epidemic  of  plague,  viz.  a  sickness  and  mortality  among  rats  and 
mice.  They  directed  attention  to  the  rat  mortality  then  accompanying 
plague  in  Hongkong  and  to  the  examination  of  some  of  the  rats,  with 
the  result  that  the  same  microbe  Avas  discovered  in  the  sick  and  dead 
rats  as  in  human  beings  affected  with  plague.  Morphologically  and 
culturally  these  microbes  are  not  to  be  distinguished  from  one  another, 
and  their  action  on  other  animals  is  the  same.  The  epizootic  among 
rats,  which  has  been  observed  to  prevail  in  nearly  every  outbreak 
of  plague  in  different  countries,  during  the  existing  pandemic  has  been 
proved  by  bacteriological  examination  to  be  plague. 

That  a  relation  exists  between  certain  epizootics  and  epidemics  of 

„  ,  ,.  ^.  plague  has  been  a  current  belief  for  many  centuries.  The 
Relationship        ^    .  . 

between  epizootic  was  generally  looked  upon  either  as  a  sign  of 

zootics^and  C(»ming  plague  or  as  the  actual  disease  attacking  animals 

epidemics  of  precedent  to  its  affecting  human  beings.     This  latter  view 

current  belief  '•'*  \ii^'\d  by  the  Chinese  at  the  present  moment  and   led, 

for  many  by  those  who   held  it,  to   the  doctrine  that  plagfue   is   a 

centuries.  -i      •  . 

soil  disease   attacking  first  the  animals  which   burrow  in 

the  ground. 

The   relationship  is   not  so   clear  as  the  many  t'xamples  cited   in 

hi-stoiy-  would   indicate,  for  plague  in  the  early  periods  was  confused 


CH.  v]  Epizootics  and  Plague  97 

with  many  other  pestilences,  and  the  confusion  applied  to  animal  diseases 

as  well.     Epizootics  occurring  at  a  period  when  plague  prevalence  was 

common  at  the  same  season  of  the  year  would  likely  be  taken  to  be 

connected  in  some  way  with  plague,  but  that  they  were  frequently  not 

related  to  that  disease,  nor  even  a  sign  of  a  coming  plague,  may  be 

gathered  from  the  fact  that  in  periods  when  plague  was  quiescent  or 

not  existing  in  the  country  there  had  been  similar  wide-spread  and 

fatal  epizootics  of  various  kinds,  which  destroyed  immense  numbers  of 

cattle,  and  which  were  called  cattle  plagues  because  of  their  fatality 

and   the   extensive    range   of  their   devastation.     The   designation    is 

retained  even  to-day  for  diseases  known  to  have  no  relation  to  plague. 

Rinderpest,  for  example,  is  a  term  which  is  applied  to  a  number  of 

diseases   not  yet   differentiated  and  classified,  and  includes  small-pox, 

haemorrhagic    septicaemia,    plague,    and    other    infective    diseases    of 

animals.     In  Rhodesia  at  the  present  day  there  prevails  a  devastating 

epizootic  called  tick  fever,  or  red  water  fever,  which  is  destroying  the 

cattle   of  the   country  and   which   is   caused  by  a  sporozoon.     Before 

the   microscope   came    into   use   for   the   diagnosis   of  cattle   diseases 

Observations       this   epizootic   would   not   have   been   differentiated   from 

of  epizootics       other  infectious  diseases  of  cattle,  and  consequently  the 

associated  ...         n        ■         •  •  i       •  c      \  • 

with  plague        relationship  of  epizootics  to  epidemics  of   plague  m  any 

epidemics.  particular  case  in  the  past  must  be  doubtful. 

With  the  discovery  of  the  plague  bacillus  in  the  rat  the  relation- 
ship of  at  least  one  epizootic  to  plague  is  established.  It  is  the 
epizootic  most  frequently  mentioned  with  plague.  The  first  reference 
to  it  is  in  Syria  some  3000  years  ago,  when  the  Philistines  at  war  with 
the  Israelites  were  attacked  with  plague,  and  they  made  golden  images 
of  their  emerods  and  of  the  mice  that  marred  the  land^ 

Avicenna  recognised  a  connection  in  Mesopotamia  and  refers  to  the 
fact  that  on  the  approach  of  plague  mice  and  other  animals,  which 
usually  live  underground,  leave  their  holes  and  move  about  in  a  stagger- 
ing manner  as  if  they  were  drunk.  The  inhabitants  of  Hindustan  were 
at  one  time  familiar  with  the  connection  between  rat  mortality  and 
plague,  for  in  the  Bharjavatd  Purano,  written  more  than  800  years  ago, 
they  are  instructed  to  leave  their  dwellings  immediately  they  notice  a 
mortality  among  rats. 

In  the  Great  Plague  of  1848  other  animals  besides  rats  arc  mentioned 
as   having   been   affected.     Nicephorus  Gregoras''^  says :   "  Nor  was  it 

'  1  Samuel  vi.  ver.  5. 

-  Nicephori  Gregoiae  Historiae  Byzuntinae  lib.  xvi.  cap.  1. 


98  Epidemiolocm  of  Plague  [part  ii 

mankind  alone  that  the  plague  thus  harassed  as  with  a  scourge,  but  all 
other  animals  that  dwell  with  or  associate  with  human  hoings  took  the 
disease;  dogs  and  horses  and  fowls  as  well,  and  even  the  mice  that  lived 
within  the  walls  of  their  houses."  This  is  corroborated  by  the  Emperor 
Cantacuzine,  who  stated  that  even  the  domestic  animals  were  carried  off 
with  plague.  A  Paduan  chronicler'  says  of  the  epidemic  of  1347  that 
once  the  sickness  entered  a  dwelling,  all  were  seized  by  it,  even  the 
animals.  When  Holstein^  was  attacked  in  1350  with  a  grievous  bubo 
plague  it  raged  both  in  the  case  of  man  and  in  that  of  cattle. 

When  the  plague  reached  Avignon*  it  is  recorded  by  Baluze  that 
even  the  animals  in  the  place,  such  as  dogs,  cats  and  hens,  died.  In 
Toumay^  the  mortality  was  especially  great  among  the  chief  people  and 
the  rich,  as  well  as  the  poor.  Deaths  were  more  numerous  about  the 
market-places  and  in  poor  narrow  streets  than  in  broader  and  more 
spacious  areas ;  and  whenever  one  or  two  people  died  in  any  house, 
at  once,  or  at  least  in  a  short  space  of  time,  the  rest  of  the  household 
were  carried  off,  so  much  so  that  very  often  in  one  home  ten  or  more 
ended  their  lives  together,  and  in  many  houses  the  dogs  and  even 
cats  died. 

At  the  time  when  the  epidemic  prevailed  in  England-'  there  was 
according  to  Knighton  a  great  mortality  of  sheep,  so  much  so  that  in 
one  place  there  died  in  one  pasture  more  than  5000  sheep,  and  they 
were  so  putrid  that  neither  beast  nor  bird  would  touch  them. 

Similar  accounts  are  given  by  Arab  authors®  as  to  its  attacking 
animals  and  birds  which  ate  the  flesh  of  infected  bodies  that  had  not 
been  buried. 

Rats,  moles,  serpents,  conies,  foxes,  badgers,  martens,  and  adders 
are  mentioned  by  later  writers  as  having  been  observed  to  die  before, 
or  during  plague  epidemics,  and  the  appearance  of  these  in  unusual 
numbers  was  usually  considered  to  be  the  harbinger  of  plague. 

Skeyne'',  in  1568,  gives  as  a  sign  of  impending  plague  the  moles  and 
serpents  leaving  their  holes,  "as  quhan  the  moudeuart  and  serpent  leauis 
the  Eird  beand  molestit  be  the  Vapore  contenit  within  the  bowells  of  the 
samin";  also  he  states,  "quhan  the  domesticall  foulis  becummis  pestilen- 
tiale,  it  is  ane  signe  of  maist  dangerous  pest  to  follow." 

'   The  Great  Peatilence,  1348-9,  F.  A.  Pasijuet,  1893. 

2  Ibid.  ■■'  Ibid.  *  Ibid.  5  iiia^ 

*  Histoire  des  Hiiuk,  Vol.  v.  p.  224.     J.  <le  (iuignes. 

^  "  Ane  Breve  Description  of  tbe  Pest,  p.  10,  by  Maister  Gilbert  Skeyne,  Doctoure  in 
Medicine,  Edin.  1568."   Edited  by  W.  F.  Skene  and  presented  to  the  Bannatyne  Club,  1860. 


CH.  v]  Rats  and  Plague  99 

In  treating  of  the  plague  in  London,  Lodge  ^  mentions  rats  and 
moles  and  other  creatures,  accustomed  to  living  underground,  forsaking 
then-  holes  and  habitations,  and  attributes  it  to  corruption  of  the  soil. 

Dr  Hodges^  in  writing  of  the  Great  Plague  of  London  of  1665,  says 
"  that  subterranean  animals,  such  as  moles,  mice,  serpents,  conies,  foxes, 
&c.  as  conscious  of  approaching  mischief,  leave  their  burrows,  and  lie 
open  in  the  air  which  is  also  a  certain  sign  of  a  pestilence  at  hand." 

It  must  be  noted,  however,  that  no  mention  is  made  of  epizootics  in 
accounts  of  many  of  the  epidemics  of  plague  in  European  cities,  though 
it  is  curious  that  in  most,  rats,  dogs  and  cats  are  ordered  to  be 
destroyed.  Dr  J.  F.  Payne  informs  me  that  in  the  plague  on  the  Volga 
in  1878  and  1879,  which  he  and  Dr  Colville  investigated,  a  large 
mortality  among  rodents  was  observed,  but  its  relationship  to  the 
epidemic  of  plague  did  not  impress  him  at  the  time.  Now  he  is 
inclined  to  think  that  the  association  was  very  intimate. 

In  the  Kathiawdr  epidemic  in  India  of  1820  mortality  and  sickness 
in  cattle  is  referred  to,  but  was  believed  to  be  due  to  other  causes. 

On  the  other  hand,  Dr  Forbes''  mentions  that  in  the  Pali  plague  of 
1836-38  the  plague  was  preceded  by  a  great  mortality  among  the 
cattle,  and  that  the  most  singular  phenomenon  was  the  death  of  all  the 
rats  in  the  village  of  Taiwali  during  the  latter  half  of  April,  and 
just  before  the  plague's  first  appearance.  Mr  White  reports,  "  they  lay 
dead  in  all  places  and  directions  in  the  streets,  houses,  and  hiding  places 
of  the  walls,"  and  "  this  death  of  the  animals  attended  or  preceded  the 
disease  in  every  town  that  was  attacked  in  Marwar,  so  that  the 
inhabitants  of  every  house  instantly  (juitted  it  on  seeing  a  dead  rat." 

The  epidemic  which  prevailed  in  Kumaon,  one  of  the  endemic 
centres  in  India,  in  1834-5  was,  according  to  Mr  Gowan,  the  Com- 
missioner, preceded  or  accompanied  by  a  great  mortality  of  rats  in 
the  village.  The  same  phenomenon  was  observed  and  commented 
on  by  Drs  Planch,  Francis,  Pearson,  Hutcheson  and  Thompson  in 
several  of  the  later  outbreaks  of  plague,  or  Mahamari  as  it  is  called 
by  the  natives,  in  Kumaon  and  Gharwal. 

In  Yunnan  in  Western  China,  another  endemic  centre  of  plague,  it 
is  to  be  gathered  from  the  reports  of  the  French  Missionaries  who 
have    resided    there,    and   from   M.    Rocher    who  visited  the   province. 


^  A  Treatise  of  the  Plague,  by  Thomas  Loilge,  Doctor  iu  Physics,  1603,  cap.  iii. 

2  Loimologia,  or  an  Historical  Account  of  the  Plague  in  London  in  16(55,  p.  42.     By 
Nathaniel  Hodges,  M.D. 

**  The  Nature  and  History  of  Plague  as  observed  in  the  North-Western  Provinces  of  India. 
By  Frederick  Forbes,  A.M.,  M.D. 

7—2 


100  Epidemiologn  of  Plague  [part  ii 

that  a  rat  mortality  preceded  the  several  outbreaks  of  plague',  and 
that  other  animals,  great  and  small,  such  as  buffaloes,  oxen,  sheep  and 
deer,  and  sometimes  also  court-yard  fowls,  died  of  the  disease. 

Mr  Davenport'-,  who  was  in  Yunnan  a  few  years  later,  mentions  cats, 
rats,  mules,  and  other  quadrupeds  as  being  affected. 

Mr  Baber,  of  H.B.M.'s  Consular  Service,  in  his  Notes  on  the  route 
of  Mr  Grosveiior's  iHi.ssion  in  Western  China,  Yurnum,  refers  to  the 
mortality  among  rats  and  poultry,  pigs,  goats,  ponies  and  oxen. 

Dr  Lowiy  states*  that  in  nearly  every  house  in  Pakhoi,  where  plague 
broke  out,  rats  were  observed  to  come  out  of  their  holes  and  die  on 
the  floor. 

Coming  to  the  present  pandemic,  a  large  mortality  of  rats  was 
noticed  in  the  first  affected  quarters  of  Canton  before  the  plague 
appeared  among  human  beings.  Later  on,  the  appearance  of  affected 
rats  in  portions  of  the  city  hitherto  immune  was  the  signal  of  the 
approaching  disease,  and  residents  who  could  afford  to  do  so  moved  to 
the  suburbs,  or  went  to  live  in  boats  moored  in  the  river.  In  Canton 
there  is  a  very  large  boating  community  which  remained  for  the  most 
part  free  of  plague.  This  comparative  immunity  of  boating  people  was 
observed  also  in  Hongkong,  and  has  been  noticed  in  the  older  epidemics 
of  Europe.  In  the  great  epidemics  of  London  many  of  the  inhabitants 
took  up  their  residence  in  boats,  because  of  the  freedom  from  plague 
which  the  boat  population  enjoyed.  The  great  mortality  among  rats  in 
Canton  may  be  judged  from  the  fact  that  22,000  rats  were  taken  out 
of  one  gate  of  the  city  and  buried.  In  Hongkong  there  was  a  great 
mortality  of  rats  during  the  plague  epidemic  of  1894,  and  the  same 
occuiTed  in  the  subsequent  annual  recrudescences. 

The  same  seasonal  influences  have  a  corresponding  effect  on  the  plague 
epizootic  and  epidemic.  From  the  chart  for  Hongkong  in  1900  pre- 
pared by  Dr  Clark,  Medical  Officer  of  Health  for  Hongkong,  and 
reproduced  on  the  opposite  page,  it  will  be  seen  that  the  rise  and  fall 
in  the  epizootic  is  similar  to  the  rise  and  fall  of  the  epidemic.  The 
very  rapid  rise  in  the  rat  mortality  antedates  the  epidemic  outbreak  for 
several  weeks  ;  it  reaches  its  maximum  a  week  or  so  before  plague  and 
declines  with  the  plague  mortality. 

In    1902   the   examination  of  rats  for  plague   was    carried    out    in 
Hongkong  on  a  most  extensive  scale  by  four  bacteriologists  engaged  on 
no  other  duties.     It  resulted  in  demonstrating  that  the  great  majority 
'  La  Province  CkhioiHe  de  Yiiniiiin.     E.  Rocher,  Paris,  1879. 
2  Commercial  Reports  from  His  Majesty^s  Conxuls,  Chiii/i.     No.  2,  1877. 
^  Notes   of  an   epidemic   disease   observed    at   Pakhoi    in    1882.     Imperial    Maritime 
Customs  Medical  Reports,  China,  for  the  year  ended  Sept.   1882.     June,   1883. 


CH.  V] 


Rats  and  Plague 


101 


of  plague  cases  in  Hongkong  in  1902  was  preceded  by  rat  plague.  A 
further  enquiry  on  the  same  lines  by  Dr  William  Hunter^  for  1903  con- 
firmed this  relationship.     The  results  for  1903  are  shown  in  the  chart 

Week    STH.   9th.  10TH.11th.12TH.I3th.14th.15th.16tH.I7th.18TH.19TH.20tH.21ST.22nd.23rD.24th.25th.26tH.2''TH.28TH.29TH.SQTH.31st.32nd.33ro.34th.35TH. 


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on  the  next  page,  which  at  the  same  time  shows  that  the  plague  in  rats 
continues  to  exist  at  a  low  level  throughout  the  non-epidemic  period  of 
plague.  The  epizootic  rises  at  the  season  when  young  rats  are  most 
numerous. 

Governed   by  the   same   seasonal   conditions,  the  plague  epizootics 
differ  in  time  only  from  the  plague  epidemics,  preceding  them  slightly. 

'  A   Research  into  Epidemic  and  Epizootic  Plague.     By  William  Hunter,  Government 
Bacteriologist,  Hongkong,   1904. 


102 


Ejndeniwlodjj  of  Plague 


[part  II 


The  precedence  of  the  epizootic  among  rats  which  is  exhibited  in 
the  charts  has  been  observed  also  in  the  villages  and  towns  of  China. 


In  an  extensive  enquiry  made  by  the  writer^  among  European  medical 
men  practising  in  Southern  China  and  among  others  conversant  with 
plague  in  the  villages,  into  the  occurrence  of  epizootics  before  or  during 
times  of  plague,  it  was  ascertained  that  the  opinion  was  practically 
unanimous  that  the  rat  mortality  is  a  precursor  of  plague.  Not  only  is 
this  opinion  held  by  the  medical  men  in  Southern  China  experienced  in 

1  Report    on    the    Cannes    and    Continuance    of    Plague    in    Hongkong.      By   W.    J. 
Simpson.  M.D.,  1903. 


CH.  v]  Rats  and  Plague  103 

plague,  but  it  is  also  entertained  by  the  Chinese  whose  villages  or  towns 
have  been  attacked  with  plague. 

Dr  A.  Lyall^  of  Swatow,  in  referring  to  the  order  of  occurrence  in 
plague,  states,  "  It  is  generally  recognised  by  the  Chinese  that  rats  die 
first.  During  the  year  I  have  often  been  told  that  '  men  are  dying  in 
such  and  such  a  street ;  rats  have  begun  to  die  in  another  street,  men 
not  yet.'"  In  Taiwan,  Formosa,  Dr  J.  Jj.  Maxwell's  experience  was  that, 
shortly  after  hearing  that  rats  were  dying  in  such  and  such  a  house,  he 
would  be  called  to  a  case  of  plague  in  the  same  house. 

In  Uganda,  recently  discovered  to  be  a  separate  focus  of  plague, 
Koch  states  that  plague  in  man  is  preceded  by  plague  in  rats,  and  that 
the  natives  of  Kisiba  leave  their  huts  on  this  sign. 

Mice  as  well  as  rats  are  sometimes,  but  not  often,  observed  to  be 
affected  during  a  plague  epidemic.  According  to  Yamagiva  mice  died 
of  plague  during  the  epidemic  of  plague  in  Formosa.  The  same 
phenomenon  was  observed  at  Yedda  in  1898  when  the  plague  was  there. 

Previous  to  the  appearance  of  the  epidemic  of  plague  in  Bombay,  a 
heavy  mortality  occurred  among  cattle,  sheep,  and  goats.  What  the 
exceptional  mortality  was  due  to  was  never  ascertained.  Pigeons 
and  cats  also  sickened  and  died  during  the  epidemic.  The  most 
conspicuous  epizootic,  however,  was  that  which  prevailed  among 
rats,  and  which  bacteriological  examination  proved  to  be  plague. 
It  broke  out  near  the  docks  and  gradually  extended  to  other  parts 
of  the  city.  It  preceded  and  ran  concurrently  with  the  epidemic 
of  plague,  and  was  accompanied  by  a  great  migration  of  rats  from 
locality  to  locality,  evidently  induced  by  alarm  on  the  part  of  these 
animals.  In  the  town  of  Mandive^  the  inspector  reported  that  in 
nearly  50  °/o  of  the  houses  he  disinfected,  he  found  dead  cats  and  rats. 

The  epizootic  among  rats  was  observed  in  most  of  the  towns  and 
villages  of  India  in  which  plague  became  epidemic.  The  same  phe- 
nomenon presented  itself  in  the  Mauritius,  Alexandria,  Oporto,  Naples, 
Cape  Town,  Port  Elizabeth,  East  London,  Durban,  and  in  Sydney  and 
Brisbane,  precedent  to  and  concurrently  with  plague  prevalence. 

Rats  when  they  sicken  with  plague  leave  their  holes  and  generally 

Plague-  come  out  into  the  open.     They  look  ill  and  are  in  a  dazed 

stricken  rats,  condition  ;  their  eyes  are  watery,  their  coats  are  partially 
their  appear-  .       ,      ^  ,     ■  ,     ,         i     i  i  ,  •  i     i-/y.      i  i 

ance  and  deprived  01  hair,  and  they  hobble  about  with  dimculty  and 

behaviour.         stagger  and  fall.     The  nervous  system  is  affected,  showing 

itself  most  often  in    lethargy,  sometimes  in  paralytic    symptoms  and 

sometimes  in  great  excitement.     They  either  make  very  little  attempt 

1  Simpson,  Ihid.  ^  The  Plague  in  India,  1896-98.     Nathan,  Vol.  n.  p.  222. 


104  Epidemiolofiy  of  Plague  [part  ii 

to  escape  when  approached,  or  they  may  rush  about  madly  or  caper 
round  the  room,  and  their  behaviour  is  so  extraordinarily  different 
from  what  is  usual  that  the  illness  from  which  they  are  suffering  may 
be  at  once  suspected. 

The  glands  of  plague-infected  rats,  especially  the  submaxillary  and 
praesternal,  are  enlarged,  and  these,  together  wuth  the  internal  organs  and 
blood,  contain  plague  bacilli.  The  tissues  are  congested  and  of  a  dark 
colour,  and  as  a  rule  have  a  sodden  or  macerated  appearance.  The  lungs 
are  congested,  exude  on  section  frothy  blood,  and  at  times  contain 
pneumonic  patches.  The  spleen  is  generally  enlarged  and  engorged 
with  blood  ;  the  liver  is  also  enlarged  and  presents  in  portions  of  it 
a  mottled  appearance.  There  are  petechial  haemorrhages  on  all  the 
internal  organs  and  under  the  pleura  and  peritoneum.  The  plague 
bacilli  on  smear  preparations  often  vary  in  appearance  according  to 
whether  the  rat  is  examined  immediately  after  death  or  later,  or  has 
suffered  from  an  acute  or  chronic  illness.  In  the  case  of  delay  in  death, 
or  in  examination,  the  bacilli  are  often  found  to  have  undergone 
involution  changes. 

Cats  suffered  from  illness,  accompanied  with  buboes  and  wasting,  in 
Cats  affected  Bombay,  Karachi,  Ahmednagar  and  Baroda.  The  Austrian 
with  plague.  Commission  caused  plague  in  three  cats  by  feeding  them 
with  the  bodies  of  animals  dead  of  plague.  One  eat  took  the  disease  in 
an  acute  form,  while  the  other  two  took  it  in  a  chronic  form,  having 
buboes  on  the  neck  and  wasting. 

In  Cape  Town  there  was  also  a  great  mortality  among  moles,  but  as 
these  animals  were  not  examined  bacteriologically  it  cannot  be  definitely 
stated  that  the  mortality  was  due  to  plague.  Cats  also  contracted 
plague  as  proved  by  post-mortem  examination  and  bacteriological 
examination,  but  not  in  great  numbers.  The  type  of  plague  was  bubonic, 
affecting  the  glands  of  the  neck  and  the  submaxillary  glands.  There 
was  sometimes  extensive  infiltration  below  the  jaw,  extending  down  to 
the  neck. 

The  post-mortem  appearances  met  with  in  the  cats  are  as  follows  ^ 

Cat  I.  Found  dying  in  the  street.  Post-mortem  showed  glands  in  neck  and 
throat  much  swollen  and  filled  with  well  marked  plague  bacilli.  Lungs  congested 
and  pneumonic,  liver  healthy,  spleen  healthy,  mesenteric  glands  much  enlarged  but 
not  congested,  subraaxil'ary  glands  much  enlarged  but  not  congested. 

Cat  II.  Submaxillary  glands  enlarged,  spleen  enlarged,  liver  normal,  glands 
along  vertebrae  enlarged,  axillary  and  groin  glands  enlarged,  blood  dark  in  colour, 
bacilli  in  blood,  enlarged  glands  and  spleen. 

'  The  post-mortems  were  made  by  Dr  Robertson,  Pathologist  to  the  Cape  Government, 
in  the  presence  of  the  author. 


CH.  v]  Cats  and  Plague  105 

Cat  III.  Submaxillary  glauds  enlarged  and  congested.  The  praesternal 
lymphatic  glands  much  enlarged  and  congested.  Right  lung  presents  patches  of 
acute  lobular  pneumonia.  Heart  blood  fluid  and  dark  in  ap[)earance,  li\er  much 
enlarged,  clayish  colour,  spleen  much  enlarged,  moderately  firm  in  texture  and 
congested,  kidneys  normal,  intestines  much  inflamed  in  condition  of  enteritis. 
There  is  a  general  inflammatory  condition  of  the  respiratory  and  digestive  organs. 
Inguinal  glands  congested,  plague  bacilli  in  the  glands. 

Cat  IV.  Cat  found  in  a  house,  ran  a  little  distance  and  then  fell  down  dead. 
Submaxillary  glands  greatly  swollen,  great  oedema  of  the  subcutaneous  cellular 
tissue  of  neck,  mesenteric  glands  enlarged  and  congested,  glands  in  the  groin  and 
praesternal  swollen  and  congested,  with  oedema  in  the  surrounding  cellular  tissues, 
spleen  normal,  digestive  system  normal,  lungs  with  patches  of  pneumonia,  plague 
bacilli  in  lungs  and  glands. 

Cat  V.  Identical  lesions  to  that  of  Cat  I V.  and  typical  plague  bacilli,  but  not  so 
numerous. 

Cat  VI.  Cat  which  had  died  after  having  been  noticed  to  be  sick  for  four  or 
five  days.  There  was  extensive  necrosis  of  the  tissues  of  the  lower  jaw.  Post-mortem 
showed  submaxillary  glands  very  much  enlarged,  periglandular  tissue  oedematous, 
and  veins  over  glands  dilated.  Praesternal  glands  on  left  side  below  pectoralis  major 
were  enlarged  and  pink  ;  lungs  were  congested,  heart  distended,  liver  dark,  soft,  and 
easily  broken  up,  spleen  not  enlarged,  kidneys  very  large  and  congested.  Plague 
bacilli  were  found  in  glands  and  in  lungs. 

Cat  VII.  Found  dead  in  a  house.  The  submaxillary  glands  were  much 
enlarged  and  there  was  an  extensive  infiltration  of  the  colourless  fluid  into  the 
subcutaneous  tissue  below  the  jaw  and  extending  down  to  the  neck,  plague  bacilli 
present  in  the  glands,  and  infiltration. 

Cat  VIII.  Found  in  a  moribund  condition  in  a  house  in  which  there  was  plague. 
The  expression  in  the  cat's  face  is  almost  typical,  head  being  triangular  in  shape, 
owing  to  great  swelling  below  jaw,  lips  thickened  and  eyes  nearly  closed. 

On  post-mortem  the  submaxillary  gland  on  right  side  was  yellow  in  colour  and 
foci  of  pus  were  formed.  The  condition  of  the  gland  on  the  left  side  was  not  so 
advanced,  but  on  section  was  soft.  Surroimding  the  glands  was  much  yellow  fluid. 
The  surface  of  the  glands  was  of  a  deep  red  colour,  and  the  vessels  were  dilated. 

There  was  a  very  large  soft  congested  gland  on  either  side  in  praesternal  region. 
The  liver,  spleen  and  abdominal  organs  were  normal.  The  lungs  were  congested 
but  not  pneumonic.  The  heart  contained  some  pericardial  fluid,  and  petechia  were 
on  its  inner  surface,  plague  bacilli  in  buboes  and  tissues. 

Cat  IX.  Killed  because  looking  ill.  Glands  under  jaw  much  enlarged,  right 
submaxillary  gland  on  right  side  suppurating.     Plague  bacilli  present. 

Cat  X.  Found  ill  in  empty  house.  Submaxillary  lymphatics  much  enlarged, 
contain  plague  bacilli. 

Cat  XI.  Found  ill  in  street.  Submaxillary  glands  very  large  and  haemorrhagic, 
contain  plagvie  bacilli. 

Cat  XII.  Found  dead  in  .street.  Submaxillary  glands  enlarged  and  haemor- 
rhagic, praesternal  gland  enlarged,  plague  bacilli  present. 


106  Epidemiology  of  Plague  [part  ii 

Dr  William  Hunter'  records  a  small  outbreak  of  ])lague  among  cats 
in  a  warehouse  in  Kowloon,  in  which  rats  had  been  previously  dying  of 
plague.  In  the  course  of  his  investigations  he  found  that  rats  fed  on 
paddy  soaked  in  the  faeces  or  urine  of  plague-infected  cats  died  of 
acute  rat  plague.  The  post-mortem  appearances  of  cat  plague  were, 
in  Hongkong,  extreme  congestion  of  all  the  tissues  and  organs,  congestion 
of  the  lymphatic  glands  with  the  presence  of  cortical  haemorrhages,  and 
frequent  bubonic  swellings  about  the  neck  and  the  mesentery ;  but,  as 
pointed  out  by  Dr  Hunter,  the  most  interesting  condition  was  found  in 
the  abdomen.  The  peritoneum  was  smooth  and  shiny.  Very  little 
fluid  was  found  in  the  peritoneal  cavity.  The  stomach  was  con- 
gested, particularly  on  its  mucous  surface  which  showed  innumerable 
haemorrhages  of  varying  size!  No  actual  ante-mortem  ulceration  was 
found.  The  small  intestine  was  in  general  reddened.  The  ileum  was 
the  seat  of  many  small  petechiae  scattered  through  its  entire  length,  the 
mucous  surface  of  which  was  reddened  and  thickened.  The  thickening 
was  chiefly  due  to  oedema.  The  solitary  follicles  were  visible,  being 
pin-head  in  size  and  greyish-yellow  in  colour.  Small  areas  of  necrosis 
were  present  which  appeared  chiefly  about  the  regions  of  haemorrhagic 
extravasation. 

In  one  or  two  cases  a  distinct  bubonic  formation  was  found  in  the 
mesentery.  Plague  bacilli  were  found  scattered  throughout  the  body, 
and  were  specially  abundant  in  the  lymphatic  apparatus  and  in  all 
bubonic  areas.  The  faeces  and  the  urine  also  contained  plague  bacilli. 
Dr  Hunter  also  observed  cases  of  chronic  cat  plague,  in  which  the  cat 
became  extremely  emaciated,  with  the  formation  of  buboes  in  various 
situations  of  the  body,  especially  about  the  neck.  The  buboes  are  very 
chronic  in  growth,  accompanied  by  extreme  surrounding  infiltration,  and 
slowly  break  down  with  the  production  of  thick  creamy  pus.  The  animals 
may  live  from  two  weeks  to  a  month.  It  is  a  marasmus,  and  is  well 
described  by  the  term  "  Pest  Marasmus." 

Other  animals  such  as  pigs,  goats,  cattle,  sheep,  fowls  and  rabbits 
suffer  from  plague  as  well  as  man. 

In  Newchang"^,  in  the  plague  epidemic  of  1899  two  months  after  the 
other  animals  first  recognised  cases  of  plague  and  at  a  time  when  many 
piag-ue  deaths  were  taking  place,  in  the  houses  and  shops  in  close 

'  A  Research  into  Epidemic  and  Epizootic  Plaijue.  By  William  Hunter,  (Tovernmeiit 
Bacteriologist,  Hongkong,  1904. 

^  Imperial  Maritime  Customs  Medical  Report  for  half-year  ended  30th  Sept.  1899,  58th 
issue,  1900.     Dr  C.  C.  Burgh  Dal>'.s  Report  on  the  health  of  Newchaiig. 


CH.  v]  Dogs  and  Plague  107 

proximity  to  foreign  residences  it  was  noticed  that  rats,  chickens, 
ducks,  geese,  pigs,  dogs,  deer,  and  cattle  were  dying  in  unusually 
large  numbers. 

Dr  Michoud,  in  describing  the  epidemic  of  1893  at  Mengtze  in  Yunnan, 
says,  "  We  saw  on  some  roads  dogs  and  pigs  feeding  undisturbed  on 
corpses  which  no  one  cared  to  bury.  These  animals  fell  victims  to  their 
voracity  and  succumbed  to  the  scourge'." 

Dr  J.  P.  Maxwell,  of  Changpo  in  the  province  of  Fokien,  mentions 
the  fact  of  dogs  occasionally  dying  with  glandular  swellings  during  the 
plague  epidemic ;  he  had  seen  four.  Surgeon-Major  Lyons  of  the 
Indian  Medical  Service  also  reports  that  in  the  case  of  a  dog  which  was 
examined  in  Bombay  there  was  post-mortem  evidence  of  it  having  been 
affected  with  plague. 

In  Cape  Town  a  dog  was  found  dying  in  a  house.  The  post-mortem 
examination  showed  the  lungs  to  be  congested  and  full  of  froth  and 
blood.  There  was  lobar  pneumonia.  Heart  was  distended  and  full 
of  tarry  blood.  Axillary  and  mesenteric  glands  were  enlarged,  with 
the  surrounding  areolar  tissue  congested.  Liver  was  congested.  Spleen 
healthy.  Kidney  enlarged  and  congested.  Plague  bacilli  were  present 
in  the  blood. 

Additional  evidence  of  the  susceptibility  of  the  lower  animals  to 
Result  of  plague   has    been    obtained    experi  men  tall}'.     By    feeding 

experiments        vvith  cultures  of  plague  bacilli,  by  inoculation  with  them 

to  produce  .  . 

pia^ein  and  by  causing  animals  to  breathe  air  containing  plague 

animals.  bacilli,  rodents,  especially  rats  and  guinea-pigs,  have  been 

found  to  be  very  susceptible.     The  disease  produced  in  them  may  be 

acute  or  chronic.     In  the  latter  form  it  may  exist  for  months.     The 

significance  of  the   disease  in  rats  will  become  more  apparent    when 

treating  of  the  continuance  and  spread  of  plague.     It  will  at  present 

be  sufficient  to   state   that  the   role  played  by  other  rodents  is  small 

compared  with  that  of  the  rat. 

As  regards  susceptibility  of  other  animals  to  artificially  induced 
plague,  experimenters  have  met  with  conflicting  results,  but  in  the 
main  the  positive  are  more  important  than  the  negative,  and  as  such 
will  be  chiefly  dealt  with. 

The  following  tabular  statements  give  a  summary  of  the  experi- 
ments on  different  animals  carried  out  by  the  German  and  Austrian 
Medical  Commissions  on  their  visit  to  Bombay. 

1  Imperial  Maritime  Customs,  China,  Medical  Reports  for  the  year  ended  30th  Sep- 
tember, 1894,  47th  and  48tli  issues,  1895 


108 


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110 


E2ndemioloffif  of  Plague 


[part  II 


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112 


Epidemloloijii  of  Plague 


[part  II 


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Ejndemiologii  of  Plague 


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CH.  v]        Experiments  by  Aiistrian  Commission 


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116  Epklemwlofiji  of  Playue  [part  ii 

In  view  of  the  intimate  association  of  the  inhabitants  of  a  great 
many  countries  with  their  cattle,  pigs,  goats,  and  fowls,  either  in  the 
farm  or  in  their  houses,  it  is  important  that  the  question  should  be 
decided  as  to  whether  these  animals  are  susceptible  to  plague.  The 
Chinese  belief  is  that  cattle,  pigs,  fowls,  as  well  as  rats  suffer  from 
plague,  and  it  is  in  accord  with  the  older  views  of  Europeans  when 
plague  was  epidemic.  Both  the  German  and  Austrian  Commissions 
failed  to  produce  plague  in  oxen,  pigs,  and  poultry.  In  the  case  of 
cats  the  German  Commission  failed  to  produce  the  disease,  while  the 
Austrian  Commission  succeeded  by  feeding.  Dogs  could  not  be  success- 
fully infected  by  feeding,  but  virulent  plague  bacilli  were  found  in  their 
Haffkine's  faeces.     HafFkine  experimented  on  horses,  cows,  sheep,  and 

experiments.  goats  by  inoculation  of  plague  cultures,  but  the  goats  alone, 
without  developing  any  acute  disease,  lost  condition  gradually,  wasted 
away,  and  after  a  considerable  time  many  of  them  succumbed.  Lowson 
experimented  on  pigeons,  ducks,  crossbills,  yellow-hammers,  linnets 
and  canaries,  and  failed  to  infect  them  with  plague.  On  the  other  hand, 
Wiim's  ex-  Wilm '  in  the  Hongkong  epidemic  of  plague  in  1896  suc- 

periments.  ceeded   in  infecting  a  pig  fed  with  the  spleen  of  a  man 

who  had  died  of  plague ;  and  a  number  of  poultry  fed  by  him  with 
plague  material  and  with  pure  cultures  of  the  plague  bacillus  died  in 
3  or  4  days  of  plague.  Piaxi  and  Posen'-  found,  when  pigeons  and 
sparrows  were  starved,  that  they  were  susceptible  to  plague. 

Further  experiments  on  a  large  scale  were  carried  out  in  Hongkong 
Experiments  ^^^  1902  by  the  writer^,  assisted  by  Dr  Hunter,  the  Govern- 
on  a  large  ment  Bacteriologist,  and  Dr  Matsuda,  a  Japanese  medical 

scale  carried  ^       r^  n  tt  ^  ^        ^ 

out  in  Hong-       nian  lent  to  the  Government  of  Hongkong  by  Japan, 
kong  in  1902.  rpj^^  result  of  these  experiments  was  to  establish  the 

fact  that  calves,  hens,  turkeys,  geese,  pigeons,  sheep  and  pigs  were 
susceptible  to  plague  both  by  inoculation  and  by  feeding,  and  that  pigs 
and  poultry  were  susceptible  in  a  high  degree. 

Plague  material  containing  the  plague  bacillus  and  taken  from 
a  plague  case  was  employed  in  preference  to  the  use  of  cultures  of 
the  plague  bacillus,  which  is  more  or  less  an  artificial  condition,  and 
it  is  probably  to  the  adoption  of  this  method  that  the  experiments  were 

1  Report  on  the  Epidemic  of  Bubonic  Plague  in  Hongkong  in  the  gear  18i)6.  By  Staff- 
Surgeon  Wilm. 

■■*  Revista  Interna  d'Igene,  April,  1897. 

^  Report  on  the  Catises  and  Continuance  of  Plague  in  llonghung  and  xuggestionn  as  to 
remedial  measures.     By  W.  ,1.  Simpson,  M.D.,  Colonial  Office,  1903. 


CH.  V] 


Experiments  in  Hongkong 


117 


attended  with  success.  The  material  for  experiment  was  always  care- 
fully examined  before  use  in  order  to  be  certain  of  its  nature.  Each 
experiment  was  checked  bacteriologically  and  by  the  effect  produced 
by  feeding  rats  on  portions  of  the  animal  which  had  been  experimented 
on.  The  bacilli  were  isolated,  and  cultures  of  them  were  made,  and 
the  effects  of  a  few  of  the  cultures  were  tested  on  guinea-pigs. 

There  were  employed  in  the  experiment  15  pigs,  7  calves,  and  1  buffalo 
calf,   31    hens,   7   pigeons,   6    turkeys,   6    geese,  6    ducks,   8    redbeaks, 

7  monkeys,  7  guinea-pigs,  and  109  rats.  The  result  is  shown  in  the 
following  statement  which  gives  the  number  and  percentage  of  the 
animals  that  died  of  plague  : — 

Of  the  15  pigs  experimented  on   13   equal  to  86  "/o  died ;  of  the 

8  calves  7  equal  to  87 "/o  died;  of  the  31  hens  11  equal  to  35 "/o  died; 
of  the  7  pigeons  all  died ;  of  the  6  geese  3  equal  to  50  "/o  died ;  of  the 
6  turkeys  4  equal  to  iiQ  "/o  died ;  of  the  6  ducks  all  died ;  of  the  3  red- 
beaks  2  died ;  of  the  7  monkeys  5  equal  to  70  "/o  died ;  of  the  7  guinea- 
pigs  all  died;  of  the  109  rats  727,,  died. 

In  the  case  of  the  first  4  pigs  experimented  on,  in  which  the  infective 
material  was  derived  from  a  human  being,  the  time  was  so 
long  before  the  animals  showed  any  signs  of  illness  that,  if  it 
had  not  been  that  suspicion  of  illness  arose  from  the  daily  temperatures 
recorded,  they  probably  would  have  been  disposed  of  at  a  date  anterior 
to  their  illness  and  counted  erroneously  as  failures.     Of  the  4  pigs  first 


Pigs. 


Chart  I. 

Temperature  of  pig  inoculated  with  emulsion  from  huho  of  plague  case  on  May 
31s<,  and  agaiii  ivith  emulsion  of  plague  pneumonic  lung  on  June  2nd. 


90» 

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118 


Epidemiology  of  Plague 


[part  II 


Chart  II. 

Tenvperature  of  fig  fed  with  emulsion  of  bubo  of  plague  case  on  May  3\st, 
and  with  emulsion  of  plague  pneumonic  lung  on  June   '2nd. 


1901. 

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Chart  III. 

Temperature  oj  a  smaller  pig  inoculated  with  bouillon  emulsion 
of  plague  pneumonic  lung. 


1902 

June         dat£s    of  observations 

2 

3 

4- 

5 

6 
f 

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Fshr 

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CH.  y] 


Experiments  in  Hongkong 


119 


experimented  on  3  were  fed  and  1  inoculated.  The  3  that  were  fed 
died  in  the  5th  week,  while  the  one  that  was  inoculated  was  killed  in 
the  5th  week,  the  seat  of  inoculation  having  become  necrosed  and  the 
inguinal  glands  enlarged.  The  temperatures  were  of  much  the  same 
type,  rising  on  the  14th  or  15th  day  and  continuing  from  that  time  at  a 
higher  range.     Of  this  type  Charts  I.  and  II.  are  examples. 

The  type  of  disease  varied  in  intensity,  however,  as  is  seen  by  Chart 
III.,  which  is  that  of  a  smaller  pig  which  was  inoculated  at  the  same 
time,  with  the  same  material  and  with  the  same  dose  as  that  used  for 
Pig  1,  the  only  difference  being  that  the  larger  pig  had  had  a  previous 
inoculation  two  days  before  with  emulsion  from  bubo  of  a  plague  case. 

Feeding  with  the  organs  of  pigs  which  had  died  of  plague  killed  in 
4,  8,  and  17  days.  Chart  IV.  represents  the  temperature  of  pig  that 
died  on  the  8th  day. 

Chart  IV. 

Temperature  of  pig  fed  with  the  organs  a,nd  hlood  of  a  pig 
that  had  died  of  plague. 


1902 

June.                             dates   of  observations.                     | 

II 

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17 

16 

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120 


Epidemiology  of  Plague 


[part  II 


Scarification  and  vaccination  on  the  abdomen  of  pigs  with  blood  and 
spleen  pulp  of  other  pigs  which  died  of  plague  killed  with  plague 
in  9  and  15  days;  while  the  same  process  with  the  haemorrhagic 
glands  of  buffalo  calf  dead  of  plague  killed  in  9  and  19  days.  A  pig, 
fed  with  the  organs  of  a  hen  which  succumbed  of  plague,  died  on  the 
13th  day. 

Chart  V.  represents  temporatui-o  of  pig  scarified  and  vaccinated  with 
blood  and  spleen  pulp,  which  died  on  the  9th  day. 

Chart  V. 

Temperature  of  pig  scarified  and  vaccinated  on  abdomen  ivith  blood  and  jndp 
from  spleen,  heart,  and  (/land  of  a  pig  tvJiicli  had  died  of  plague. 


1302 

June.                              dates    of  observations. 

1 1 

12 

13 

14- 

15 

16 

17 

18 

19 

20 

Cent 

Fahr 

AM ;  pw 

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The  symptoms  in  the  pig  were  undefined  at  first  and  nothing 
indicated  illness  except  a  higher  temperature  than  usual.  The  first 
noticeable  symptoms  were  slight  dulness,  and  lethargy,  though  this  was 
often  absent,  congested  eyes  sometimes  becoming  very  intense  with 
mucous  discharge,  great  difficulty  in  walking,  the  hind  legs  appearing 
not  to  be  quite  under  control,  and  causing  the  pig  to  stagger  and  to  be 
very  unsteady.     The  staggering  gait  is  evidently  due  to  paralysis  or  loss 


CH.  v]  Experiments  in  Honf/konr/  121 

of  co-ordinating  power  in  the  nerve  centres.  The  appetite  was  good  up 
to  the  last.  In  some  there  was  diarrhoea  on  the  last  day.  Death  as 
a  rule  was  sudden,  the  symptoms  of  serious  illness  being  of  short 
duration  in  most  of  them. 

The  post-mortem  appearances  were  great  congestion  and  haemor- 
rhagic  condition  <jf  the  glands ;  in  two  cases  the  neck  glands  were  the 
worst  affected.  The  large  intestines  were  congested  in  those  that  had 
been  fed,  in  the  others  they  were  healthy.  The  bladder  was  always 
congested.  Plague  bacilli  were  found  in  the  blood,  organs,  and  glands, 
and  in  scrapings  from  the  bladder.  They  were  also  in  the  urine,  and 
in  the  discharges  from  congested  eyes. 

In  the  calves  experimented  on  the  disease  ran  a  more  rapid  course 

than  in  the  pig  when  the  infection  was  derived  from  a 
Calves.  1111. 

human    case,    and    was    considerably  accelerated  when    the 

infection  was  conveyed  from  calf  to  calf  The  symptoms  were  as  ill- 
defined  as  in  the  pig.  There  was  a  certain  amount  of  dulness,  the 
glands  felt  swollen  and  were  evidently  tender,  and  the  animal  lost 
weight.  Suddenly  a  comatose  condition  would  set  in.  The  post-mortem 
appearances  were  those  of  congestion  and  infiltration,  especially  in  the 
region  of  the  neck. 

Chart  VI.  represents  the  temperature  of  a  calf  fed  on  May  29th 
with  emulsion  of  bubo  from  plague  case  and  on  June  2nd  with  emulsion 
of  plague  pneumonic  lung. 

Hens  fed  with  plague  material  from  human  plague  died  on  the  10th, 

11th  and  15th  day;  those  inoculated  died  on  the  15th  day, 
Fowls. 

while  those  inoculated  or  fed  with  material  from  a  plague- 
infected  hen,  or  from  a  calf,  or  from  a  pig,  or  a  rat,  died  as  rapidly  as  the 
2nd  or  3rd  day. 

Turkeys,  geese  and  ducks  suffered  from  an  acute  or  chronic  form 
of  plague  ;  one  type  being  fatal  in  a  few  days,  the  other  in  a  month  to 
7  or  8  weeks. 

An  interesting  experiment  was  the  feeding  of  a  monkey  with  a 

banana,  the  inside  of  which  was  smeared  with  the  blood  of 
^^^'  a  rat  which  had  died  of  plague.  The  symptoms  were  in  all 
respects  similar  to  those  induced  by  inoculating  a  monkey  with  the  same 
material.  Both  showed  a  rise  of  temperature  on  the  3rd  day,  with 
dulness,  weakness  and  death  on  the  sixth  day.  The  post-mortem  appear- 
ances were  general  congestion  of  the  organs  of  the  body,  congested  glands 
without  any  marked  symptoms  of  enlargement  and  bacilli  in  blood  and 
organs. 


122 


Epidemiology  of  Plague 


[part  n 


Chart  VI. 

Temperature  of  a  calf  fed  rmth  emulsion  of  bubo  from  plagtte  case, 
and  4  days  later  with  cmidsion  of  plague  pneumonic  lung. 


1902 

UAf                                 JUUE                                  DATES     OF    OBSERVATIONC                                                              JUNE.                                                          | 

29 

30 

31 

1 

2 

3 

A 

5 

6 

7 

e 

3 

10 

11 

12 

13 

1* 

15 

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am:pm 

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am:pm 

am:pm 

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AMPM 

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AMPM 

AM :  pmJam : pmJam:  pmJam  :  pm|am  : pm 

AM :  PM  AM :  pm| 

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Another  monkey  fed  in  a  similar  fashion  on  another  occasion 
remained  well.  The  positive  experiment  demonstrates,  however,  that 
rat  plague  is  communicable  to  the  higher  animals.  A  similar  experiment 
in  1896  by  Wilm,  in  which  a  monkey  was  given  a  piece  of  sugar-cane 
infected  with  a  pure  culture  of  the  plague  bacillus,  and  died  in  5  days, 
showed  in  the  post-mortem  examination  a  very  slight  swelling  of  the 
inguinal  glands,  great  congestion  of  the  intestines,  and  sw^elling  of  the 
mesenteric  glands  and  of  the  spleen. 

In  another  experiment  a  rat  dead  of  plague,  with  no  visible  fleas 
about  it,  but  which  had  been  opened  for  post-mortem  examination,  was 
placed  in  a  cage  with  a  monkey.  The  temperature  of  the  monkey  rose 
on  the  third  day;  great  dulness  set  in  at  the  same  time,  which  continued 
for  three  days,  after  which  it  lessened,  and  the  monkey  appeared  to  be 
getting  better.  There  was  later  a  relapse,  and  death  occurred  on  the 
10th  day.  There  were  the  same  post-mortem  appearances  as  in  the 
mt)nkey  inoculated  or  fed  with  plague  material,  and  there  were  plague 
bacilli  in  the  spleen  and  glands,  but  only  a  few^  in  the  blood. 


CH.  V] 


Experiments  in  Homfkong 


123 


The  exact  manner  in  which  the  monkey  with  the  plague-infected 
rat  in  its  cage  became  infected  it  is  difficult  to  decide.  It  may  have 
been  by  inoculation  caused  by  scratching,  or  by  infection  of  the  mouth, 
the  fingers  of  the  monkey  becoming  infected  by  touching  the  rat ;  or  it 
may  have  been  possibly  though  unlikely  due  to  fleas  from  the  rat 
passing  to  the  monkey,  or  it  may  have  been  caused  by  the  fleas  of  the 
monkey  passing  to  the  rat,  and  then  again  settling  on  the  monkey. 

With  the  object  of  endeavouring  to  settle  this  point,  two  monkeys 
were  placed  in  specially  constructed  cages  along  with  rats  dead  of 
plague  but  so  separated  as  to  prevent  any  possibility  of  contact.  The 
cages  each  consisted  of  three  compartments,  the  middle  compartment 
being  separated  from  those  at  each  end  by  rails,  which,  while  permitting 
small  objects  to  pass  between  them,  effectually  prevented  the  monkey 
in  the  compartment  at  one  end  putting  his  hand  through  to  reach  or 
touch  the  rats  in  the  compartment  at  the  other  end.     The  walls  of  the 

Chart  VII. 

Temperature  of  monkey  inoculated  with  blood  from  a  rat  dead  of  plague, 
which  had  died  froin  feeding  on  the  organs  of  a  plague-infected  buffalo 
calf. 


1902 

JU  M  E  .                                      DATES    OF   OBSERVAHOHS. 

13 

10. 

15 

16 

17 

18 

19 

4 

Cent. 

fahr 

M'.PK 

»m:«i 

AM:na 

»m:pii 

im«:pm 

kn:pM 

nri:PM 

UR.'Ptt 

hm'.ph 

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1 '. — 

124 


Epideunolofiy  of  Plague 


[part  II 


cages  were  constructed  of  mosquito  wire  netting,  which  prevented  fleas 
in  the  cage  getting  outside,  though  they  might  readily  pass  from  one 
compartment  of  the  cage  to  the  other. 

In  one  cage  a  monkey  was  placed  in  one  compartment,  and  a  rat 
sick  of  plague  in  the  compartment  at  the  opposite  end.  This  rat  was 
covered  with  fleas.  Taken  out  three  days  after,  there  were  no  fleas  on 
it.  The  monkey  on  the  4th  day  had  a  temperature  of  104-6  deg.  It 
became  dull,  did  not  eat,  and  was  evidently  sick,  remained  in  a  drowsy 
state  with  its  head  down  on  its  breast,  and  with  its  hand  to  its  head ; 
but  after  this  illness  had  continued  for  nearly  a  week  it  recovered.  In 
the  other  case  a  monkey  was  placed  in  one  compartment  and  four  dead 
rats  in  the  compartment  at  the  other  end.  The  monkey  on  the  3rd  day 
had  a  temperature  of  103-8  deg.  It  also  became  dull  and  drowsy  and 
was  evidently  sick,  but  in  a  few  days  it  also  recovered. 

Chart  VIII. 

Temperature  of  a  monkey  placed  in  the  same  cage  as  a  rat  dead  of  plague  and 
which  had  been  opened  and  exam,ined.      Hat  was  quite  free  of  fleas. 


IS02 

J  U  N  B  .                                          DATES     OF    OBSERVATIONS 

13 

14- 

15 

16 

17 

18 

19 

70 

21 

Cent 

Fahr 

^m:pn 

.'.m :  PM 

ah:  pv 

AM :  PH 

AM :  PM 

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CH.  V] 


Experiments  in  Hongkong 


125 


The  temperature  and  course  of  the  disease  induced  by  the  several 
methods  employed  are  seen  in  Charts  VII.,  VIII.,  IX.  and  X.  The  type 
and  duration  of  the  disease  are  much  the  same,  irrespective  of  the 
channels  of  infection. 

Chart  IX. 

Temperature  of  monkey  placed  in  cage,  having  a  rat  dead  of  plague  in 
adjoining  cage,  hut  with  impossibility  of  contact.  Rat  was  covered  with 
fleas. 


1902 

June.                July.           dates    of  oBSEKVAnoNs. 

26 

27 

28 

29 

30 

1 

2 

3 

Cent 

Fahr 

am;pm 

am;  pn 

AM  :  PM 

am:pm 

AM :  PM 

am:pw 

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AM  :pm 

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Sheep. 


A  sheep  fed  with  a  bouillon  emulsion  of  spleen  from  a  septicaemic 
case  died  of  plague  in  34  days,  while  another  sheep  fed  on 
blood  from  a  calf  which  died  of  plague  was  affected,  and  died 
of  plague  on  the  10th  day.  The  chief  symptoms  were  difficulty  of 
breathing  and  great  weakness.  Post-mortem  showed  the  spleen  and 
internal  organs  congested,  glands  haemorrhagic,  lungs  much  congested, 
with  black  patches,  bladder  healthy,  large  intestines  haemorrhagic,  small 
intestine  and  stomach  healthy.  Plague  bacilli  were  found  in  blood, 
spleen,  kidneys,  bladder  and  glands. 


126  Epidemiolo(jij  of  Plague  [part  ii 

Three  clogs   fed  with    material   from  a   bubo  remained  Avell,  apart 

from  a  rise  in  temperature.     The  German  Commission  and 
Do&rs. 

Ogata  likewise  failed  to  produce  plague  experimentally  in 

dogs.     The   Austrian   Commission,    though  unable   to   cause   illness  in 

dogs    fed    with    plague-infected    material,    recovered    highly    virulent 

plague  bacilli  from  the  excreta  of  the  dogs. 

Variation  in  susceptibility  was  observed  in  rats  fed  with  the  organs 

of  animals   which    had   died    of  plague.     Some   rats   took    the   disease 

rapidly  and  were  dead  of  plague  by  the  second  day ;  others  did  not  die 

for  a  week,  a   fortnight,  or  even  3  weeks  after  they  were   fed,  while 

others,  nearly  30  per  cent.,  were  not  affected. 

From  the  experiments  it  is  shown : — 

I.  That  pigs,  poultry  and  cattle  are  susceptible  to  plague  whether 

derived  from  the  infection  of  a  human  being  infected  with 
plague,  or  from  their  own  species,  or  from  some  other  animal. 
Sheep  are  also  susceptible. 

II.  That   plague   among  animals   may  be  acute  and  rapid  in  its 

termination,  or  chronic  and  slow  in  its  course.  In  neither 
case  may  the  symptoms  be  very  marked. 

III.  That  the   animals  take   the   infection  of  plague  as  easily  by 

feeding  with  plague  material  as  by  inoculation. 

IV.  That    plague    material    from    man,    pigs,   poultry,    cattle,  and 

monkeys  will  give  plague  to  rats,  and  that  plague  material 
from  rats  will  give  plague  to  monkeys  by  feeding,  by  in- 
oculation, by  contact  and  without  contact ;  and  if  to  monkeys, 
probably  to  man  by  the  same  channels. 

The  facility  with  which  these  animals  take  plague  by  feeding  is  a 
very  important  point  and  it  is  possible  that  plague  in  man 
man  possibly  is  not  infrequently  contracted  by  the  swallowing  of  plague- 
not  mfre-  infected  food  contaminated  by  an  infected  rat,  or  by  the 
quently  .  ^  \  -^ 
caused  by           uncleanliness  of  those  preparing  the  food  ;  the  frequently 

taminated  congested  condition  of  the  stomach  and  intestines  of  plague 

with  plague  patients,  as  well  as  the  occurrence  of  tonsillar  plague, 
serve  to  give  countenance  to  this  view.  Emphasis  has 
recently  been  given  to  this  opinion  by  Dr  Hunter  of  Hongkong,  who 
has  observed  diarrhoea,  vomiting  or  colic  to  precede  the  fever  in  a 
number  of  cases  of  plague.  Since  these  experiments  were  made,  and 
more  attention  directed  to  the  markets  in  Hongkong  on  account  of 
the  knowledge  as  to  the  susceptibility  of  poultry,  some  of  the  poultry 


CH.  v]  Experiments  in  Natal  127 

exposed  for  sale  there  have  been  discovered  to  be  affected  with  plague 
during  the  plague  season. 

The  chronic  and  ill-defined  character  of  plague  among  some  of 
the  animals  perhaps  also  explains  the  endemicity  of  the  disease  in  those 
localities  in  which  pigs  and  poultry  share  the  living-rooms  of  the 
inhabitants,  and  by  their  close  association  become,  under  favourable 
circumstances,  subjected  to  the  risk  of  contracting  each  other's  diseases. 
The  same  character  probably  also  explains  the  apparent  absence  of 
plague  in  a  locality  during  the  non-epidemic  season. 

While  these  enquiries  were  proceeding,  opportunity  arose  of  ex- 
amining into  a  fatal  epizootic  among  cattle  which  has  occurred  every 
year  since  plague  began  in  Hongkong.  Investigation  showed  that  it 
was  not  plague,  nor  was  it  that  rinderpest  which  visited  South  Africa, 
but  that  it  was  a  systemic  disease  manifesting  itself  mainly  in  the 
intestinal  tract  and  causing  at  times  a  haemorrhagic  condition  of  the 
lymphatic  glands.  The  causal  agent  was  apparently  a  diplococcus  or 
diplobacillus  present  in  the  organs  of  the  body,  in  the  urine  and  in  the 
excreta,  and  probably  infecting  the  fodder. 

Further  investigations  of  this  disease  by  Dr  W.  Hunter,  Government 
Bacteriologist,  and  Mr  A.  Gibson,  Colonial  Veterinary  Surgeon,  confirm 
the  results  obtained  in  the  preliminary  research  and  prove  that  the 
micro-organism  is  constantly  present.  They  conclude  that  the  disease 
is  a  form  of  haemorrhagic  septicaemia  and  is  allied  to  Pasteuralosis. 
Apart  fi-om  the  importance  of  the  identification  of  this  haemorrhagic 
septicaemia  and  the  differentiation  from  other  diseases  of  cattle,  the 
prevalence  of  such  a  disease  when  plague  is  epidemic  shows  that 
epizootics  other  than  plague  may  be  readily  and  erroneously  taken  for 
plague ;  and  that  nothing  but  a  careful  bacteriological  examination  of 
the  animals  affected  can  decide  the  question. 

Similar  experiments  to  those  carried  out  in  Hongkong  were  repeated 
in  Natal  ^  by  the  medical  authorities,  but  these  experiments  failed  to 
produce  the  disease  in  pigs,  fowls,  or  cattle.  There  may  be  several 
explanations  of  this.  In  the  first  place  the  experiments  were  not 
carried  out  during  the  epidemic  season,  which  is  always  an  important 
factor,  and  secondly  the  plague  microbe  in  the  epidemic  of  Natal  may 
not  have  had  that  virulence  which  belongs  to  the  bacillus  in  China. 
The  great  difference  in  severity  of  symptoms  and  fatality  of  the  plague 
in  China  and  that  in  South  Africa  has  already  been  referred  to.  There 
may  also  be  a  more  or  less  comparative  racial  immunity  among  animals 
1  Report  on  the  Plague  in  Natal,  1902-3,  by  Ernest  Hill,  Health  Officer  for  the  Colony. 


128  Epidemiol 0(1!/  of  Plague  [part  ii 

in  one   country  as  compared  with  another,  similar  to  that  prevailing 

among  human  beings. 

The  susceptibility,  which  the  animals  referred  to  exhibit  in  regard 

Plague  in  ani-     ^^  experimental  plague,  is  not  confined  to  the  laboratory 

mais  under         .^Yiw  more    than    it    is   to    the    rat,  but   occurs  at  times 
conditions  of  ''  ,.   .  •      ,i       <•  p        •  ■  tx 

natural  under  natural  conditions  in  the  lorm  oi  epizootics.     How 

infection.  frequently    and     under    what     conditions    has     still     to 

be  ascertained. 

Epizootics  of  plague  other  than  among  rats  and  cats,  and  under 
natural  conditions,  have  been  positively  demonstrated  in  a  few  instances. 
In  China  pigs  and  poultry  have  been  discovered  to  have  been  attacked 
by  plague  under  natural  conditions.  In  Hongkong^  it  was  demonstrated 
in  1896  by  bacteriological  evidence  that  a  ship-load  of  pigs,  imported 
from  a  locality  infected  with  plague,  died  of  the  disease. 

In  1903"  poultry  in  the  markets  of  Hongkong  were  proved  to  have 
died  of  plague.  In  Kunkhal*  near  Hurdwar  in  the  north-west  provinces, 
and  in  Jawalapur  in  1897,  and  in  Gadag  near  Dharwar  in  1898,  monkeys 
were  observed  to  fall  from  the  trees  and  die  in  the  streets,  and  on 
examination  were  found  to  be  plague-stricken.  Some  had  buboes  on 
them,  and  the  plague  bacillus  was  isolated  from  their  tissues.  Monkeys 
were  also  observed  to  be  attacked  by  plague  in  other  localities  in  India. 

In  Gadag  a  squiri'el^  was  proved  on  bacteriological  examination  to 
have  died  of  plague,  and  squirrels  died  in  Hubli,  in  Poona,  in  Bangalore, 
in  Baroda,  and  other  places  during  the  occurrence  of  plague  in  those 
localities. 

In  Sydney  in  1902',  during  the  second  outbreak  of  plague  in  that 
city,  eleven  animals  in  the  Zoological  Gardens  were  positively  ascertained 
to  be  infected  with  plague.  These  consisted  of  four  wallabies,  one 
wallaroo,  one  pandemelon,  one  tree-kangaroo,  one  Indian  antelope,  and 
three  guinea-pigs. 

There   is  considerable   evidence®  to  support  the  view  that  a  fatal 

'  Report  of  the  Epidemic  of  Jluhonic  Plague  in  Hongkoiuj  in  the  year  1896.  By  Staff- 
Surgeon  Wilm. 

2  Report  to  the  Sanitary  Board  of  Hongkong,  June,  1903. 

3  Thirtieth  Annual  Report  of  the  Sanitary  Commissioner  of  the  North-West  Provinces 
and  Oudh  for  the  year  ending  31st  December,  1897. 

■*  "Plague  in  Monkeys  and  Squirrels,"  by  Alice  Corthorn,  M.B.,  Indian  Medical 
Gazette,   1899. 

®  Report  of  the  Board  of  Health  on  a  second  outbreak  of  Plague  at  Sydney,  1902,  by 
J.  A.  Thompson,  M.D.,  D.P.H.         ^ 

•^  "Plague  in  Siberia  and  Mongolia  and  the  Tarbagan  (Arctomys  bobac),"  by  Frank 
Clemow,  M.D.,  Journal  of  Tropical  Medicine,  Feb.  1900. 


CH.  v]  Chronic  Plague  in  Animals  129 

sickness,  which  sometimes  prevails  in  a  epizootic  form  among  a  species 
of  marmot  known  as  the  Tarbagan  (Arctomys  bobac),  is  plague,  but 
hitherto  there  has  been  no  direct  bacteriological  proof  of  this.  This 
disease  has  been  observed  to  affect  the  tarbagans  in  Aksha,  in  the 
Siberian  pi'ovince  of  Transbaikal,  and  also  in  the  valley  of  Solenko  in 
Eastern  Mongolia  to  the  north-east  of  Pekin. 

In  the  different  epidemic  manifestations  of  the  existing  pandemic 
no  important  epizootic  other  than  that  prevailing  among  rats  has  been 
observed,  such  as  is  recorded  in  some  of  the  older  plague  epidemics. 
But  the  examples  cited  indicate  that  there  is  always  a  possibility  of 
plague  becoming  prevalent  among  many  of  the  lower  animals  on 
the  occasion  of  a  severe  epidemic,  and  that  the  disease  among  these 
animals  may  be  an  important  agency  in  the  maintenance  and  dis- 
semination of  plague  in  an  infected  locality.  In  this  connection  the 
chronicity  of  plague  in  some  of  the  animals  experimented  on  in 
Hongkong,  the  chronic  form  of  plague  as  observed  in  guinea-pigs  by 
Albrecht  and  Ghon  in  their  experiments,  and  the  chronic  plague 
existing  in  rats  for  months  as  shown  by  Kolle  and  Martini  are  im- 
portant as  explaining  the  prolonged  continuation  of  plague  in  endemic 
centres. 


CHAPTER   VI. 

DIFFERENT   VIEWS   AS   RECxARDS   THE   ETIOLOGY   OF 
PANDEMICS   AND   EPIDEMICS   OF   PLAGUE. 

The  discovery  of  the  plague  bacillus  has  as  already  stated  put  an 
end  to  the  theory  of  the  cause  of  plague  being  a  gaseous  emanation 
from  the  soil,  and  to  the  possibility  of  spontaneous  generation  inde- 
pendent of  the  plague  bacillus.  The  power  of  growth  and  rapid 
reproduction  which  the  bacillus  displays  when  sown  on  a  favourable 
medium  supptn-ts  the  view  that  the  infective  agent  of  plague,  notwith- 
standing its  feeble  resistance  to  many  hostile  influences,  is  able  to 
maintain  its  existence,  in  at  least  some  quarters  of  the  globe,  and  ■ 
there  to  flourish  in  man,  in  animals,  or  in  the  soil.  The  continuity 
of  plague  as  thus  understood,  and  its  connection  with  homes  of  plague, 
temporary  or  permanent,  are  in  direct  opposition  to  the  doctrine  of  the 
spontaneous  origin  of  plague  from  particular  or  local  conditions.  This 
latter  hypothesis  arose  in  great  measure  from  failure  in  the  past  to 
be  able  to  trace  a  connection  between  great  epidemics  in  different 
places.  But  as  plague  became  rarer  in  Western  Europe  during  the  18th 
and  19th  centuries,  and  nearly  every  plague  epidemic  was  traceable  to 
a  fresh  importation  from  the  East,  the  doctrine  of  the  spontaneity  of 
plague  in  a  non-infected  locality  was  considerably  weakened,  to  be  still 
further  weakened  by  the  facts  ascertained  in  the  present  pandemic, 
when  the  facilities  for  tracing  of  cases  and  for  chronicling  them  have 
been  better  than  at  any  previous  period.  The  specific  nature  of  the 
infection,  its  differentiation  from  those  infections  causing  other  diseases, 
such  as  typhus,  relapsing  fever,  malaria,  and  typhoid  fever,  which  were 
formerly  confused  with  plague,  and  the  facilities  for  tracing  the  course 
of  plague  from  one  locality  to  another,  are  factors  which  have  assisted 
in  establishing  the  non- spontaneity  of  the  origin  of  plague. 

The  present  pandemic  has  exhibited  an  insidious,  slow,  steady,  and 
widely  distributed   dispersal  of  the  infection  from  infected  centres  to 


CH.  vi]  Parisefs  Theory  *  131 

healthy  localities,  and  it  can  be  definitely  stated  that  as  far  as  modern 

plague  is  concerned  there  is  no  such  thing  as  spontaneous  origin  in  a 

non-infected    locality,  and    that    an    outbreak,   except    in    an    endemic 

centre,  is  invariably  due  to  importation  of  the  bacillus.     On  the  other 

hand  in  endemic  regions  the  possible  long  vitality  of  the  plague  bacillus, 

the  facilities  which  the  microbe  obtains  of  passing  through  the  lower 

animals,  without  attracting  any  special  attention  either  on  account  of 

the  slightness  of  the  symptoms  or  the  chronicity  of  the  disease  produced, 

together  with  the  variability  of  the  bacillus    in  losing  and  acquiring 

virulence  in  some  unknown  way,  certainly  clothe  the  origin  of  plague 

in  man  with  an  apparent  spontaneity. 

A  knowledge  of  the  nature  of  the  infection  may  be  decisive  enough 

in   negativing'  the   spontaneous  origin    of  plague,  but  it 
Some  ques-  *  ^  ^ .  ,        * .  i"    &      ' 

tions  related       does  not  settle  questions   closely  allied    to  that  of  spon- 

to  spon-  taneity,  viz.  how  does  the   bacillus   retain  or  acquire  its 

taneity.  •'  \  ^ 

specificity  and  virulence,  and  what  are  the  determining 

factors  in  the  diffusive  qualities  of  plague  ?     Virulence  of  the  microbe 

is    an    inconstant    factor,    and    may    be    so    weakened    as    to    lose    the 

power  of  producing  a  recognisable  specific  disease.     In  what  way  can 

that  virulence  be  retained  or  exalted  ?     It  is  from  this  aspect  that  the 

older  views  of  the  origin  of  plague  may  be  considered. 

For  centuries  the  origin  of  the  virus  or  infection  of  plague  has  been 

Origin  of  suspected  to  be  due  to  putrefaction  of  dead  bodies  brought 

plague  long  about  by  improper  disposal,  or  by  great  physical  dis- 
attributed  to  .  •        ,         ,  <•  mi        i  •  i 

putrefaction       turbances  in  the  phenomena  oi  nature.      Ihe  disturbances 

of  dead  themselves,  or  their  effects,  have  also  been  held  to  be  not 

bodies,  or  to 

great  physical     only    the    originators    of  plague,   but    also    the    cause    of 

ances.      pandemics  and  epidemics. 

Pariset\  who  was  one  of  the  Commissioners  from  France  to  study 
the  plague  in  Syria  and  Egypt  in  1829,  first  gave  scientific  shape  to 
this  old  hypothesis  that  putrefaction  of  the  bodies  of  the  unburied 
or  imperfectly  buried  is,  under  certain  conditions,  the  origin  of  the 
plague  virus. 

Observing  on  the  occasion  of  his  investigations  into  plague  in 
Pariset's  Egypt  the  condition  of  corpses  buried  in  a  soil  subjected 

theory.  ^^  inundations,  Pariset  came  to  the  conclusion  that  these 

putrefying  corpses  and  the  })utrid  emanations  from  them  were  the 
source  and  origin  of  the  plague  virus,  and  the  cause  of  the  endemicity 

'  Memoire  sur  les  Causes  de  la  Peste  et  sitr  les  moyens  de  la  detruire.     Par  M.  Etienne 
Pariset.     Paris,  1837. 

9—2 


132  Epi(lenuoIo<i!/  of  Plague  [part  ii 

of  plague  in  that  country,  which  he  took  to  be  the  birth-place  of  the 
disease.  In  the  ehiboration  of  his  views  he  enters  into  the  history  of 
Egypt  in  regard  to  the  disposal  of  the  dead,  showing  that  the  ancient 
Egyptians  down  to  the  Christian  era  were  most  careful  of  their  dead, 
embalming  them  and  thus  preserving  them  from  the  putridity  which 
burial  in  a  water-logged  soil  brings  about.  With  the  advance  of 
Christianity  these  precautions  gradually  passed  into  desuetude.  Pariset 
says:  "The  admirable  police  arrangements  for  sepulture  were  abolished. 
What  a  false  zeal  accomplished  at  Constantinople,  at  Rome,  at  Milan, 
in  all  the  towns  of  the  two  empires,  was  done  also  in  Egypt.  The 
bodies  of  the  martyrs  and  of  the  faithful  filled  the  houses,  the  churches 
and  the  cemeteries  as  at  the  present  day,  and  after  a  century,  or  a 
century  and  a  half,  the  new  method  of  honouring  the  dead  caused  one 
of  the  most  terrible  plagues  in  history  to  break  out  at  Pelusium." 

Following  this  up  he  shows  that  under  the  Arabian,  and  particularly 
the  Turkish  rule,  Egypt  gradually  lost  its  high  estate,  sank  from  a 
fertile  country  with  a  healthy  and  highly  civilised  population  into  one 
in  which  the  inhabitants  were  more  or  less  slaves,  ill  fed,  badly  housed, 
and  uncleanly;  dwelling  in  huts  and  houses,  damp  and  over-crowded, 
and  so  built  as  to  be  without  fresh  air  or  sufficient  light.  It  was  under 
these  conditions  the  Copts  had  their  family  vaults  in  their  houses,  and 
every  time  one  of  the  family  died  the  slab  of  the  vault  was  raised  and 
a  new  corpse  deposited  on  the  older.  Sometimes  these  vaults  contained 
80  to  90  bodies,  and  the  family  was  only  separated  by  a  plank.  There 
were  at  the  time  of  the  enquiry  300  Coptic  houses  in  Cairo,  nearly  all 
occupying  the  centre  of  the  city.  To  these  insanitarj^  conditions,  more 
particularly  the  poisonous  emanations  from  putrefying  bodies  in  a  wet 
soil,  and  in  the  vicinity  of  dwellings,  Pariset  ascribes  the  endemicity  of 
plague  in  Egypt. 

Creighton,  50  years  afterwards,  adopts  a  similar  view  as  to  the  origin 

of  the  plague  virus,  which  he  believes  to  be  derived  from 
Creighton  ,  i  ,  ^         ,  •       ,  •   •  ,,      • 

supports  the  crude  products  of  cadaveric  decomposition  |)ollutmg 

Pansefs  ^^iQ  soil  and  sub-soil.     Earth-born  in  this  wise,  the  plague 

views.  _  '  r     ^) 

virus  could  be  carried  by  merchandise  and  by  persons  to 
localities  in  similar  conditions  as  regards  putrefaction  to  those  in  which 
the  virus  was  generated,  and  finding  them  favourable  for  development 
infect  the  soil  and  the  emanations  from  it,  causing  thereby  an  outbreak. 
With  this  special  affinity  for  the  products  of  cadaveric  decomposition 
the  virus  of  plague  in  the  great  epidemic  of  1348  found  in  England  a 
congenial  soil  in  the  monasteries  and  in  the  homes  of  the  clergy.     It 


CH.  VI J  Creiffh ton's   Views  133 

may  be  remarked,  however,  that  the  monasteries  were  the  centres  of 
record,  and  accordingly  it  would  be  of  them  that  the  most  details  of  the 
ravages  of  the  epidemic  would  be  given. 

"  Within  the  walls  of  the  monastery,  under  the  floor  of  the  chapel 
or  cloisters,  were  buried  not  only  generations  of  monks,  but  often  the 
bodies  of  princes,  of  notables  of  the  surrounding  country,  and  of  great 
ecclesiastics.  In  every  parish  the  house  of  the  priest  would  have  stood 
close  to  the  church  and  the  churchyard.  One  has  to  figure  the  virus  of 
the  Black  Death,  not  so  much  as  carried  by  individuals  from  place  to 
place  in  their  persons,  or  in  their  clothes  and  effects,  but  rather  as  a 
leaven  which  has  passed  into  the  ground,  spreading  hither  and  thither 
therein  as  if  polarising  the  adjacent  particles  of  the  soil,  and  that  not 
instantaneously  like  a  physical  force,  but  so  gradually  as  to  occupy  a 
whole  12  months  between  Dorset  and  Yorkshire.  Sooner  or  later  it 
reached  to  every  corner  of  the  land,  manifesting  its  presence  wherever 
there  were  people  resident.  Such  universality  in  the  soil  of  England 
we  have  reason  to  think  it  had.  But  it  appears  to  have  put  forth  its 
greatest  power  in  the  walled  town,  in  the  monastery,  and  in  the  neigh- 
bourhood of  the  village  churchyards" 

The  mortality  of  rats  and  other  animals  in  endemic  centres  of  plague 
Mortality  of       antecedent  to,  or  during  an  outbreak  of  plague,  has  always 

rats  from  XqwX,  support  to  the  theory  that  the  soil  is  the  probable 

plague  not  ^  ^  ''       ,  ^ 

against  Pari-      manufactory  of  the   plague   virus.     It  was  not,  however, 

se  s  eory.  m^til  1894,  that  the  two  diseases  were  proved  to  be 
identical.  The  discovery  of  the  plague  bacillus  disproves  the  emana- 
tion h}^othesis,  though  it  does  not  affect  the  question  as  to  the 
soil  being  the  seminary  and  seed-plot  of  the  microbe.  It  rather 
strengthens  it  than  otherwise.  The  fact  that  the  rat  suffers  from  a 
septicaemic  variety  of  plague,  occasioned  sometimes  at  least  by  canni- 
balistic propensities,  puts  a  new  aspect  on  the  subject  of  the  relationship 
of  plague  to  the  soil.  It  not  only  shows  that  the  older  observers  were 
partly  right  in  their  observations  as  to  there  being  a  connection  between 
plague  and  the  soil,  but  it  also  explains  what  that  connection  is,  and 
how  the  plague  can  reach  the  dwellings  of  the  inhabitants.  Plague  is 
carried  slowly  hither  and  thither  by  rats  containing  the  ])lague  bacillus 
in  their  bodies  and  in  their  excretions.  Burial  of  plague  corj)ses  in 
endemic  centres  is  always  imperfect,  as  is  the  case  with  the  burial 
of  the  dead  generally,  and  it  is  within  the  range  of  probability  that 
some  rats  at  least  acquire  their  infection  from  dead  bodies  of  men 
'  History  of  Epidemics  in  Great  Britain,  Creightou,  p.  175,  1891. 


134  Epidemiology  of  Plague  [part  ii 

and  animals.  In  Cairo  the  Coptic  vaults  were  not  likely  to  have 
been  quite  safe  against  the  attacks  of  these  vermin. 

It  would  appear  that  plague  is  a  disease  that  under  certain  circum- 
stances attacks  animals  other  than  rats  as  well  as  man.  It  may  then 
be  that  the  bacillus  regains  or  acquires  its  virulence  from  an  animal  or 
series  of  animals  through  which  it  passes,  and  that  some  animal  strains 
are  more  capable  than  others  of  infecting  the  general  animal  kingdom. 
In  the  pandemic  of  1348,  more  than  any  other,  except,  perhaps,  the 
Justinian  or  Byzantine  plague,  animals  of  all  kinds  seem  to  have  been 
as  susceptible  as  man.  These  questions  are  unhappily  at  present  in 
the  domain  of  speculation  and  they  must  remain  there  until  money 
is  expended   in   scientific  research  for  their  elucidation. 

Great  calamities  of  a  cosmic  or  telluric  nature  have  been  assigned  as 
the  cause,  not  only  of  the  generation  of  the  plague  virus, 
plague  attri-  but  also  of  the  virulence  and  diffusiveness  necessary  to 
butedto^eat  j-^nder  the  disease  epidemic  or  pandemic.  Plague  may 
cosmic  and  manifest  itself  in  one  city  or  district  by  a  few  cases ;  in 
another  by  a  great  epidemic ;  or  it  may  overrun  a  pro- 
vince or  country  or  one  or  two  hemispheres.  It  is  obvious  that  other 
factors  besides  the  mere  presence  of  the  causal  agents  of  plague  must 
come  into  play  in  determining  such  very  different  results.  Volcanic 
eruptions,  earthquakes,  the  unusual  conjunction  of  certain  planets, 
irregular  seasons,  floods,  droughts,  famines,  and  the  putrefaction  of  dead 
bodies,  have,  one  and  all,  been  brought  into  requisition  as  special  causes, 
but  to  an  age  which  is,  more  or  less,  unftimiliar  with  any  continuous 
succession  of  extraordinary  physical  disturbances,  the  causes  appear 
to  be  somewhat  remote  in  their  action  and  fantastical  in  their  con- 
ception. The  list  includes  influences  which  are  likely  only  to  have  a 
subsidiary  effect.  The  two  great  consequences  of  these  catastrophes 
are  the  ensuing  putrefaction  of  the  dead,  and  the  miserable  condition  of 
the  living,  whose  homes  and  food  have  been  destroyed.  These  de- 
pressing conditions  are  generally  favourable  to  the  revivification  and  to 
the  rapid  and  wide  extension  of  any  endemic  disease.  India  furnishes  a 
number  of  instances  in  which  cholera  has  broken  out  in  epidemic  form 
after  a  destructive  inundation,  as  for  example  in  the  severe  epidemic 
which  affected  the  survivors  of  the  great  tidal  wave  which  swept  over 
the  Sunderbunds  in  Bengal  in  1879.  The  natural  resistance  of  those 
who  escaped  the  flood  was  probably  reduced  by  the  shock  which  they 
had  suffered  and  by  the  depressing  influence  of  inadequate  shelter  and 
insufficient  food. 


CH.  vi]  Precedents  of  the  Black  Death  135 

The  antecedents  in  Asia  of  the  great   pandemic   of   1348,  given  "* 

in  Deffuignes'  Histoire  Generale  des  Hans,  and  made  use 
The  Black  .... 

Death  pre-  of  by  Hecker  in  his  Epidemics  of  the  Middle  Ages,  are  a 

distm-bances*     succession  of  extraordinary  and  exceptional  events  denoting 
in  the  balance     s(jrae  great  deviation  from  the  ordinary  sequence  charac- 
teristic of  the  phenomena  of  nature  and  its  seasons. 

Deguignes  follows  the  Arab  historian  Mahassin,  who  records  the 
commencement  of  the  plague  in  Tartary  and  its  connection  with  the 
smell  of  corpses  arising  from  the  perishing  of  men,  beasts,  and  even 
birds  in  the  disastrous  floods.  The  infection  thus  produced  obtained  a 
ready  means  of  transport  westwards  by  the  northern  caravan  route, 
whose  European  marts  were  on  the  Caspian  and  the  Black  Sea,  and  by 
which  gateway  it  entered  Europe. 

Hecker  places  the  commencement  of  the  Black  Death  in  China,  and 
attributes  the  virulence  of  the  disease  and  its  pandemicity  to  the  mighty 
revolutions  of  the  earth  which  are  recorded  to  have  preceded  it. 

"'From  China  to  the  Atlantic,  the  foundations  of  the  earth  wei'e  ^ 
shaken.  Throughout  Asia  and  Europe  the  atmosphere  was  in  com- 
motion and  endangered  by  its  baneful  influence  both  vegetable  and 
animal  life."  He  writes  of  a  succession  of  inundations,  earthquakes  and 
famines,  which,  commencing  in  China,  spread  over  the  greater  part 
of  the  known  world,  and  it  is  in  China  the  great  pandemic  is  held  to 
have  originated. 

Creighton,  while  accepting  the  origin  of  the  plague  virus  from  the 

decomposition  of  corpses,  is  perplexed,  like  many  others 

places  th^  ^^^^*^  \\-^i\^  given  the  subject  their  attention,  to  find  that 

origin  of  the       though  in  China  from  1333  to  1352  there  are  records  of 

Black  Death 

on  the  borders     great  physical  disasters  with  great  mortality  ensuing,  there 

of  the  Euxine  ^^^  j^^  entries  in  the  chronicles  of  a  great  plague  until  the 
or  Black  Sea.  .  &  r    & 

latter   year.     For   this   reason,  and   because   there   were 

special  conditions  at  the  European  entrepots  on  the  Black  Sea  favour- 
able to  the  development  of  epidemic  disease,  he  shifts  the  place  of 
commencement  to  the  marts  on  the  Black  Sea.  What  were  then  the 
conditions  of  the  emporia  or  European  termini  of  the  trade  from  the 
Far  East  to  cause  them  to  be  suspected  as  the  principal  factors  in  the 
generation  and  birth  of  the  Black  Death  ? 

Creighton^   describes    these    conditions   on   the   authority   of    the 

1  The  Epidemics  of  the  Middle  Ages,  p.  11.      By  J.  F.  C.  Hecker,  M.D. 
-  History  of  the  Epidemics  of  (ircat  Britain,   Vol.   i.  p.  144.     By  Charles  Creigliton, 
M.A.,   M.D.,  1891. 


13(5  Epi(lemioli)(i[i  of  Plague  [part  ii 

manuscript  of  Gabriel  de  Mussis,  a  jurist  of  Piacenza,  who  had  been 
practising  as  a  notary  or  advocate  among  the  Genoese  and  Venetians 
trading  around  the  shores  of  the  Euxine  and  Caspian. 

It  was  at  a  time  when  these  shores  and  the  country  north  of  them 
were  harassed  by  the  Tartar  hordes.  Among  other  incidents,  the 
Italian  merchants  were  besieged,  first  at  Tana,  then  at  Cafifa.  The 
siege  of  the  latter  town  was  maintained  for  three  years,  and  caused 
those  invested  to  be  put  to  great  straits.  Plague  broke  out  in  the 
Tartar  array  and  the  dead  bodies  were  thrown  by  the  besiegers  from 
their  war  engines  into  the  town,  so  that  the  infection  took  hold  of  those 
within  the  fort.  The  mortality,  however,  became  so  great  among  the 
Tartars  that,  panic-stricken,  they  fled  from  the  siege  and  spread  the 
plague  wherever  they  went.  It  was  then  that  some  Italian  traders,  and 
Gabriel  de  Mussis  with  them,  escaped  from  Caffa  in  a  ship  and  arrived 
in  due  course  at  Genoa,  where  plague  broke  out  in  a  most  deadl}-  form  a 
few  days  after,  although  none  of  those  on  hoard  luere  suffering  from 
the  disease. 

In  making  a  choice  between  the  origin  of  the  plague  virus  among 
the  Tartar  hordes  besieging  the  merchants  within  the  walls  of  Caffa  and 
the  pre-existence  of  that  virus  for  a  long  time  latent  among  the  goods 
or  effects  of  the  besieged,  Creighton  gives  the  preference  to  the  latter 
hypothesis  on  the  ground  of  advantage  in  probability;  why  the  latter 
should  be  chosen  rather  than  the  former  is  not  very  clear.  Three 
or  more  years  is  a  long  time  for  the  virus  to  be  latent  in  towns  with  the 
conditions  prevailing  in  Tana,  Caffa,  and  Sarai,  whereas  it  is  not 
an  uncommon  event  for  plague  to  be  associated  with  armies  in  the  field 
in  that  part  of  the  world.  The  explanation  is  a  reasonable  one  if 
the  facts  and  conditions  set  forth  by  de  Mussis  were  correct,  but 
unfortunately  there  is  a  doubt  as  to  the  accuracy  of  the  account  given 
by  him,  who  is  looked  upon  rather  as  another  Daniel  de  Foe  than 
a  recorder  of  facts  of  which  he  himself  was  an  eye-witness.  The 
lower  region  of  the  Volga  was  the  scene  of  an  intense  exaltation 
of  the  plague  virus  as  recently  as  1879,  when  a  mild  manifestation  of 
plague  in  Astrakhan  suddenly  assumed  a  most  virulent  form,  but  this 
was  in  the  depth  of  winter  and  without  any  attendant  decomposition  of 
a  special  character  and  without  the  acquisition  of  diffusive  powers.  As 
a  matter  of  fact  it  was  a  self-limiting  plague,  though  the  virulence  was 
extremely  violent. 

The  account  given  by  Creighton  cannot  be  said  to  literally  agree 
with  that  given  by  de  Mussis  in  his  manuscript,  for  instead  of  no  one  on 


CH.  vt]  War  and  the  Black  Death  137 

board  suffering  from  the  plague  it  states  that  on  departure  there  were  a 
few  sailors  on  board  infected  with  the  pestilential  disease,  and  out  of 
a  thousand  passengers  and  crew  in  the  several  ships  scarce  ten  survived 
when  the  ships  arrived  at  Genoa.  Literally  translated  by  Dr  J.  F.  Payne 
from  the  Latin  manuscript,  a  copy  of  which  is  given  by  Haeser,  the 
account  is  as  follows  : 

"^In  the  year  1346  innumerable  tribes  of  Tartars  and  Saracens 
perished  in  these  regions  by  an  inexplicable  disease.  Whole  tracts  of 
country,  innumerable  provinces,  splendid  kingdoms,  cities,  camps,  and 
towns  abounding  in  population  were  attacked  by  a  horrible  death,  and 
in  a  short  time  denuded  of  their  inhabitants.  Now  a  town  called 
Thanna,  in  the  eastern  region  towards  the  north,  a  place  trading  with 
Constantinople,  was  besieged  and  conquered  by  a  great  army  of  Tartars  ; 
and  it  happened  that  the  Christian  merchants,  driven  out  by  force,  took 
refuge  within  the  walls  of  Caffa,  which  the  Genoese  had  formerly  built 
in  that  region.  Suddenly  the  infidel  tribes  of  Tartars,  collecting  from 
all  sides,  surrounded  the  city  and  besieged  the  Christians,  who  were 
shut  up  there  for  nearly  three  years ;  when  lo !  a  disease  attacked  the 
Tartars,  and  the  whole  of  the  besieging  army  fell  into  a  state  of 
weakness  and  disorder  so  that  many  thousands  of  them  died  daily.  It 
seemed  to  the  besieged  Christians  as  if  arrows  were  shot  out  of  the  sky 
to  strike  and  humble  the  pride  of  the  infidels,  who  rapidly  died  with 
marks  on  their  bodies  and  lumps  in  their  joints  and  several  parts, 
followed  by  putrid  fever ;  all  advice  and  help  of  the  doctors  being  of  no 
avail.  Whereupon  the  Tartars,  worn  out  by  this  pestilential  disease, 
and  falling  on  all  sides  as  if  thunderstruck,  and  seeing  that  they  were 
perishing  hopelessly,  ordered  the  corpses  to  be  placed  upon  their  engines 
and  thrown  into  the  city  of  Caffa.  Accordingly  were  the  bodies  of  the 
dead  hurled  over  the  walls,  so  that  the  Christians  were  not  able  to  hide 
or  protect  themselves  from  this  danger,  although  they  carried  away  as 
many  dead  as  possible  and  threw  them  into  the  sea.  But  soon  the 
whole  air  became  infected,  and  the  water  poisoned,  and  such  a  pestilence 
grew  up  that  scarcely  one  out  of  a  thousand  was  able  to  escape. 

"  Thus  were  the  Orientals  in  all  parts,  both  those  who  lived  on  the 
southern  shore  and  those  on  the  north,  struck  down  by  this  pestilential 
disease,  and  almost  all  of  them  died.  So  great  was  the  mortality  that 
Kathayans,  Indians,  Persians,  Medes,  Armenians,  Georgians,  Turcomans, 
Arabs,  Saracens,  and  Greeks  throughout  the  whole  of  the  East,  gave 
themselves  up  to  clamour,  weeping,  and  sighs,  and  remained  in  this 
'  Plagues  Ancient  and  Modern.     St  Thomas'  Hospital  Keports.     Vol.  xvii. 


138  Epidemiolociy  of  Plague  [part  ii 

distress  from  the  above-mentioned  year  to  1348,  expecting  that  the  Day 
of  Judgment  was  at  hand. 

"  Now  it  so  happened  that  a  ship  left  the  aforesaid  land  of  Caffa, 
having  on  board  a  few  sailors  (who  were  also  infected  with  the  pesti- 
lential disease),  and  made  for  Genoa,  some  other  ships  going  also  to 
Venice  and  otheis  to  other  parts  of  Christendom.  Marvellous  to  relate, 
whenever  the  navigators  arrived  at  any  land,  as  if  some  malignant 
spirits  accomi)anied  them,  wherever  they  mingled  with  other  men  the 
latter  perished.  Every  city,  every  town,  every  country,  and  their 
inhabitants  of  both  sexes,  poisoned  by  the  pestiferous  contagion  of 
the  diseased,  fell  a  prey  to  sudden  death,  and  when  one  began  to  be 
sick,  soon  falling  and  dying,  he  poisoned  the  whole  of  the  family.  Those 
who  came  in  to  bury  the  bodies  perished  by  the  same  disease.  Thus 
whole  cities  and  castles  were  made  desolate,  and  only  the  waste  places 
themselves  were  left  to  mourn  for  their  dead  inhabitants. 

"Alas  !  when  our  ships  arrived  at  any  city,  and  we  entered  our  houses, 
our  relatives,  our  connections  and  neighbours  flocked  in  to  see  us  from 
all  sides,  because  we  were  still  in  bad  health,  and  out  of  a  thousand  who 
sailed  with  us  scarce  ten  survived ;  but  alas !  we  carried  with  us  the 
arrows  of  death.  And  while  they  were  embracing  and  kissing  us  we 
could  not  help  pouring  out  poison  from  the  lips  with  which  we  spoke. 
So  they,  returning  to  their  houses,  soon  poisoned  their  own  families, 
and  within  three  days  the  whole  household,  struck  down,  succumbed 
to  the  dart  of  death,  and  the  number  of  the  dead  increased  so  much 
that  the  ground  was  not  sufficient  for  their  graves.  Priests  and  doctors, 
whom  their  great  care  for  the  sick  compelled  to  be  present  at  the  death- 
bed, alas !  returned  home  sick  themselves  and  quickly  followed  the 
deceased." 

The  account  by  de  Mussis  as  literally  transcribed  consorts  more  or 

less  with   other  contemporary  authors   who   mention  the 

considera-  prevalence  of   the  pandemic  in   Central  Asia  and    India 

tions  snowing      i  i 

the  difficulty  before  its  entrance  into  Europe.  The  disease  being  ac- 
and  even  the  i  • ,     i  i        •         i  -mi.  j. 

impossibiiity      credited  as  having  begun  in  lartary  may  mean  any  part 

of  now  ,)f  Asia,  for  the  vast  empire  of  Kublai  Khan  still  remained, 

locating  the  .       ^  .  111  1 

origin  of  the       though  broken  up  into  many  sections  and  ruled  over  by 

14th  century  j^-^  descendants  and  lieutenants.  There  were  Tartars 
pandemic. 

everywhere    in    power  from    Hungary  in   Europe    to   the 

eastern  coast  of  China.     The  westward  wave  of  that  great  invasion 

of  Mongols  begun  by   Gengiz   Khan   had  not  yet  ebbed,  and  Tartar 

and  Turkish  kingdoms  were  established  on  the  coasts  of  the  Persian 


CH.  vi]  Effect  of  Volcaiiie  Eruptions  139 

Gulf  and  the  Black  Sea  as  they  were  around  the  Caspian.  It  is 
difficult  enough  at  the  present  day  in  times  of  peace,  and  with  the 
facilities  which  steam  and  electricity  afford,  to  locate  the  origin  of  any 
pandemic.  We  have  examples  of  this  in  the  pandemics  of  cholera  and 
influenza  of  the  19th  century.  They  were  never  traced  to  any  particular 
source,  or  to  any  special  set  of  conditions.  The  source  of  the  recent 
pandemic  of  influenza  became  a  very  movable  affair  if  the  localities 
from  which  it  is  believed  to  have  originated  are  taken  into  account. 
It  was  ultimately  supposed  to  come  from  Russia  or  some  part  of  the 
Russian  dominions  which  extend  over  the  greater  part  of  Northern  Asia, 
and  it  has  even  been  pushed  back  further  to  some  remote  and  unknown 
part  of  China.  The  tendency  at  all  times  is  to  locate  the  origin  of  rare 
diseases  in  some  distant  and  unknown  country.  Plague  in  recent  years 
has  been  given  a  theoretical  endemic  area  in  Thibet,  a  country  into 
which  no  one,  until  the  British  Expedition  of  1904  forced  its  way  in, 
has  been  permitted  to  enter,  and  about  which  nothing  is  known.  Once 
creating  an  imaginary  home  in  this  unknown  country  plague  is  supposed 
to  have  travelled  down  to  Yunnan  in  China  on  one  side,  and  Kumaon 
and  Garhwal  in  India  on  the  other.  These  are  all  matters  of  assump- 
tion which  it  is  impossible  to  affirm  or  deny.  Until  the  world  is  circled 
with  the  telegraph,  and  that  which  has  happened  even  in  remote  places 
is  immediately  known,  it  will  not  be  easy  to  locate  the  exact  place 
where  a  pandemic  takes  its  origin.  All  that  is  known  of  the  origin  of 
the  plague  of  1848  is,  that  having  prevailed  in  a  malignant  form  for 
several  years  in  the  East,  it  entered  Europe  by  the  Black  Sea,  and 
probably  also  by  the  caravan  routes  of  Mesopotamia  and  Asia  Minor, 
and  that  it  occurred  at  a  time  when  the  division  of  the  Mogul  or  Tartar 
empire  on  the  death  of  Kublai  Khan  caused  large  portions  of  Asia  to 
be  a  constant  seat  of  warfare. 

Volcanic  eruptions  have  on  occasion  apparently  given  rise  to  disease 

in  a  limited  degree.    Humboldt  relates  that  in  an  eruption  of 

eruptions  are     Cotopaxi  SO  many  fish  of  the  order  Pimelodus  were  ejected 

recorded  to        that  they  poisoned  the  air  all  round,  and  it  is  recorded  by 

dered  plants      Pouchet  that  near  the  end  of  the  18th  century  the  town 

and  Herbage       ^£  go^rra  was  ravaged  by  a  malignant  fever,  which  was 
poisonous.  .  .  r 

attributable  to  the  miasmata  arising  from  the  decompo- 
sition of  an  enormous  number  of  those  fish  vomited  by  a  neighbouring 
volcano.  Humboldt  again  relates  in  his  travels  that  at  the  end  of 
violent  earthquakes  the  herbs  that  covered  the  Savannahs  of  Tucuman 
acquired  noxious  properties,  and  that  an  epidemic  disorder  broke  out 


140  Epi(leimolo(jji  of  Plague  [part  ii 

among  the  cattle,  and  a  great  number  of  them  appeared  stupefied  or 
suffocated  by  the  deleterious  vapours  exhaled  by  the  ground.  If  herbs 
can  be  rendered  poisonous  in  this  way,  it  may  be  possible  that  low 
vegetable  organisms  such  as  bacilli  can  acquire  virulent  properties  under 
similar  conditions,  or  disturbances  of  Nature. 

Atmospheric  causes  of  a  far-reaching  character,  which  are  followed 

by  lean  and  fat  years  of  famine  and  plenty,  are  not  without 

pUcation  of         their   influence   on   germ    life   in   the   lower  plant   orders. 

disease  germs  Di'ouerhts.  floods  and  other  cosmic  disturbances  which  are 
associated  o  .  i        ■        i  j 

with  lean  or  destructive  to  the  grain  and  food  of  man  and  annnals,  and 
famine  years.  ^^,j-,|(.)-,  .^,.^,  productive  of  famines  and  general  misery,  do 
not  appear  to  be  injuiious  to  the  germs  of  disease.  On  the  contrar}', 
while  the  higher  orders  of  plants  wither  and  die,  the  lower  orders,  among 
which  may  be  included  the  plague  bacillus,  appear  to  find  in  the 
exceptional  circumstances  conditions  highly  favourable  to  a  rapid  and 
luxuriant  growth. 

Exceptional    circumstances    of  weather   and    other   adverse    events 
were  not  wanting  in  Hongkong,  in  India,  in  Bombay  or 

Exceptional  [^  ^.he  Cape  to  favour  the  development  of  plague,  once  the 
meteoro-  .    ,       .  .  ^         ^         c^  ,■  ■  ,       ^i 

logical  infection    was    introduced.      home    time   previous  to   the 

'^ receded^  outbreak  of  plague  in  1894  several  extraordinary  pheno- 

tbe  epidemic       meiia  were  noticed  in  Hongkong.    The  year  before  extreme 

Hong^g!"       cold  prevailed  during  the  winter,  and  for  three  days  the 

Peak  was  covered  with  ice  to   within  about  400   feet  of 

the  sea  level,  and  the  hills  on  the  mainland  opposite  Hongkong  were 

covered  with  snow.     In  the  autumn  of  1891,  1892,  1893,  and  1894,  an 

epidemic  of  caterpillars^  Thialleta  signifera  and  Pharazia  bicarsisatis, 

attacked  the  trees  and  grass  in  Hongkong  in  such  multitudes  that  the 

Government  employed  men  to  gather  them,  for  which  they  were  paid 

at  a  certain  rate.     Then  the  flowering  of  the  male  bamboo  was  noticed, 

and  this,  combined  with  an  eclipse  of  the  sun  and  the  other  phenomena, 

presaged,  according  to  the  Chinese,  an  epidemic  of  some  kind. 

If  the  signs  of  the  times  could  have  been  read  aright,  they  would 

have  indicated  that  India  was  under  conditions  specially 
Scarcity  pre-  ... 

ceded  plague      favourable  to  the  maintenance  and  spread  of  some  epidemic 

in  India.  disease.     In  1896  there  was  failure  of  the  crops  over  a  con- 

siderable part  of  the  country,  creating  scarcity  and  a  rise  in  the  price 
of  food.     Large  numbers  of  famine-stricken  or  destitute  people  flocked 

^  Reports  of  the  hotuniciil  ami  Ajfori'stdiioii  Department  for  Iloniikonf],  1892,  1893,  and 
1894. 


CH.  vi]  Abnormal  Seasons  141 

from    the    famine    districts    into    Bombay.     In    1897   the   famine   area 

became  more  extensive  and  there  were  severe  earthquakes  in  the  eastern 

parts  of  India.     The  inference  is  not  that  either  of  these  was  the  cause 

of  the  plague,  but  that  their  occurrence  showed  an  abnormal  atmospheric 

and  terrestrial  condition  which  was  likely  to  favour  the  epidemicity  of 

plague  once  introduced  into  the  country. 

Cases  of  plague  occurred  in  Bombay  as  early  as  May  1896,  but  it 

was   not  until   the   following  October  that    the  disease   attracted   any 

special  attention  and  began  to   spread.     The  local  phenomena  which  ^ 

preceded    the    epidemic    are    described   by  Dr  Weir,   the 
Aonormal  ■■  ■■• 

season  pre-         Health    Officer^      The    mean   temperature    of    the   year 

demic  of^'  "^'^^  SO'TO,  which  was  the  second  highest  on  record  during 

plague  in  the  previous  51  years.     The  total  fall  of  rain  amounted 

°°^  ^^'  to  87*6  inches,  which  was  15  inches  above   the   average. 

It  was  not  only  above  the  average,  but  it  was  abnormal  also  in 
distribution  and  in  duration.  The  heavy  rainfall,  owing  to  an  ob- 
struction in  the  sewage  outfall,  flooded  with  sewage  the  low-lying 
portions  of  the  city,  through  which  the  polluted  streams  rushed  in 
swirling  currents,  leaving  banks  of  mud  and  sludge  behind  to  ferment 
or  dry  slowly,  and  although  the  monsoon  practically  ceased  in  August, 
the  shady  sides  of  the  streets  in  crowded  portions  of  the  city  remained 
damp  long  afterwards.  In  September  only  1'6  inches  of  rain  fell,  being 
as  much  below  the  average  as  the  earlier  months  had  been  above. 
Even  in  the  famine  years  of  1876-77  the  September  rainfall  was  not 
less  than  4  inches.  An  abnormal  September  was  followed  by  an 
abnormal  October,  dry  and  warm.  In  September  the  godowns  in 
Mandvie,  the  district  in  which  plague  first  broke  out  epidemically, 
were  still  damp. 

The  city  appears  to  have  been  in  an  exceptional  plight  due  to  an 
abnormal  season  of  rainfall,  that  lasted  only  about  half  the  normal 
period,  and  which  produced  an  abnormally  high  level  of  sewage  in  the 
arterial  sewers,  and  soakage  of  the  grain  in  dark  and  damp  godowns  or 
granaries  underneath  human  dwellings.  All  traffic  to  the  island  was 
interrupted  for  five  days.  The  grain  lay  in  the  wet.  The  low-lying 
portions  of  Bombay  were  under  water.  At  the  most  distant  points  on 
the  esplanade,  near  the  head  of  the  drainage  system,  water  welled  up 
through  the  man-holes.  The  subsoil  water  welled  up  where  it  had 
never  been  seen  before,  and  wflls  overflowed  that  had  never  previously 
been  full.  Dr  Weir  lays  stress  on  the  fact  that  during  this  ])eriod  wet 
1  Report  of  the  Health  OJicer  for  Bombay  for  18'J6,  p.  (JIO. 


142  Epidemiology  of  Plague  [part  ii 

grain  was  stored  in  wet  granaries  with  no  means  of  ventilation.  These, 
he  remarks,  are  the  conditions  most  favourable  to  the  generation  of 
disease,  and  had  it  been  necessary  to  cultivate  the  microbe,  it  would 
not  have  been  possible  to  have  created  artificially  more  fevourable  con- 
ditions, i.e.  organic  matter,  moisture,  warmth,  and  darkness.  These 
were  the  conditions  which  existed  in  the  granaries,  in  the  floors  above 
which  the  disease  first  became  epidemic. 

A  similar  abnormal  season  preceded  the  epidemic  outbreak  of  plague 

in  Cape  Town  in  1901,  which  occurred  at  a  time  of  war 
Unusual  ^        _ 

season  pre-  and  scarcity.  The  season  at  the  beginning  of  the  year 
demicof^  was  altogether  exceptional.     It  was  cold  when  it  should 

plague  in  have  been  hot,  wet  when  it  should  have  been  dry,  and  in 

C3.136  Town 

every  way  it  was  abnormal.  The  rainfall  in  January  was 
abnormal,  and  was  the  heaviest  recorded  since  1842  when  observations 
began  to  be  made.  In  this  respect  the  conditions  of  Cape  Town  corre- 
sponded with  those  of  Bombay  in  1896,  when  the  outbreak  of  plague 
in  September  was  preceded  by  an  exceptional  season  and  abnormal 
rainfall  in  July  and  August.  In  Cape  Town  a  rare  comet  was  visible 
for  several  nights. 

It  will  be  seen  that  the  explanations  of  the  causes  of  the  origin  and 

development  of  pandemics  and  epidemics,  as  distinguished 
Conclusion.  ^  .   /  i  •        i  i 

from  the  conditions  which  have  been  generally  observed  to 

favour  their  continuance  and  spread,  are  all  within  the  region  of  specu- 
lation. To-day  we  are  no  nearer  their  explanation  than  our  predecessors, 
who  ascribed  them  to  the  anger  of  the  gods,  to  astronomical  conjunctions, 
to  putridity,  to  epidemic  influences,  and  to  numerous  other  causes.  All 
that  is  definitely  known  is  that  pandemics  and  epidemics  are  generally 
associated  with  unusual  seasons  which  bring  distress  and  misery,  with  war 
and  famine  and  their  attendant  ills,  with  political,  social  or  economical 
conditions  which  are  the  reverse  of  prosperous,  and  which  produce 
general  depression  in  the  community,  and  also  with  a  laxity  or  absence 
of  sanitary  administration  which  prevents  or  hinders  prompt  dealing 
with  the  earlier  cases.  They  also  acquire  their  ascendancy  owing  to 
incomplete  knowledge  as  to  the  different  modes  by  which  they  spread, 
and  as  to  the  laws  governing  these.  Some  of  the  modes  are  known, 
but  others  being  unknown  there  is  always  the  risk,  even  when  adminis- 
trative action  is  prompt,  of  the  ])reventive  measures  employed  being 
only  partially  successful  in  checking  and  controlling  the  disease. 


CHAPTER   VIL 

VARIATION    IN   POWERS   OF   DIFFUSION   OF   EPIDEMICS  AND 
THE   EFFECT   OF   SEASONAL   INFLUENCES   ON   THEM. 

Variation  in  powers  of  diffusion  is  indicated  by  the  terms  sporadic, 
epidemic,  and  pandemic,  which  are  applied  to  plague, 
diffusive  When  the  disease  is  imported  into  a  country  it   is  im- 

powers.  possible  to  foretell   which  quality  it  will  assume,  or  how 

long  it  will  continue  to  retain  the  quality  it  first  displays.  There  are 
Seif-Umiting  self-limiting  plagues  and  there  are  plagues  which  possess 
piagTies.  great  powers  of  diffusion,  but  the  exact  conditions  under 

which  each  obtains,  or  which  determine  the  one  or  the  other,  or  by 
which  the  one  is  distinguished  from  the  other  before  its  results  are 
known,  are,  as  will  be  surmised,  still  a  matter  for  research.  The  factors 
controlling  the  diffusion  of  plague  are  really  unknown.  The  Cyrenaic, 
Mesopotamian,  and  Persian  outbreaks  during  the  fifties,  sixties,  and 
seventies  of  the  19th  century  were  shown  by  Tholozan  to  be  self-limited. 
They  spread  to  a  certain  extent  and  then  stopped,  not  because  of  the 
preventive  measures  taken,  for  they  were  usually  applied  either  too  late 
or  not  at  all,  but  because  of  some  general  law  which  is  not  yet  under- 
stood. The  plague  at  Vetlianka  was  a  self-limiting  plague.  When 
alarm  was  aroused  most  energetic  measures  were  applied,  but  not  until 
the  disease  had  spent  itself  Like  the  local  outbreak  at  Benghazi  in 
Northern  Africa  and  in  the  Assyr  district  in  Western  Arabia,  the  outbreak 
at  Vetlianka  began  and  ended  within  a  comparatively  circumscribed  area. 

The  existing  pandemic,  though  it  may  seem  paradoxical  to  say  so, 

possesses  comparatively  small  diffusive  qualities,  notwith- 

pande^lc"^       standing  its  success  in  reaching  a  large  number  of  countries. 

possesses  Its  tendency  in  most  places  where  it  has  acquired  a  footing 

tiveiy  small        is  not  to  spread  to  any  great  extent.     This  may  be  only 

diffusive  g^  temporary  characteristic,  for  India  is  an  exception.     But 

powers.  .,..,,  .  -  .  .        . 

even  in  India,  with  the  rapid  means  of  intercommunication 

which    the    country  possesses,    the    extension    of   the    disease    is   com- 


144  Ep\(JcmU)hHiii  of  Plague  [part  ii 

paratively  limited,  and  does  not  compare  with  the  progress  of  the 
14th  century  or  the  6th  century  epidemic,  or  with  the  pandemics  of 
influenza  and  cholera  of  the  19th  centur}'.  On  the  whole  the  mani- 
festation of  plague  in  ditferent  places  has  been,  with  the  exception  of 
India  and  China,  more  sporadic  than  epidemic.  Nowhere  as  yet  have 
the  great  ravages  common  to  the  towns  and  villages  of  India  and 
Southern  China  been  repeated  elsewhere. 

A  great  sowing  of  seed  has  been  effected,  but  apparently  for  the 
most  part  on  ground  which  is  barren  or  only  slightly  favourable  to 
growth.  Telegraphic  and  postal  communications  have  brought  civilised 
countries  into  such  intimate  relationship  with  one  another  that  outbreaks 
of  plague  of  any  considerable  size  are  immediately  heard  of,  and  their 
progress  followed  in  a  manner  that  was  never  possible  before.  Never 
before  has  there  been  such  an  opportunity  of  watching  so  closely  the 
gradual  scattering  of  the  seed  over  an  area  of  the  globe  which  has  for 
centuries  been  free  of  plague.  The  European  powers  at  the  Venice  Con- 
vention of  1897  agreed  to  notify  to  each  other  any  case  of  plague  in  their 
respective  dominions  coming  to  their  official  notice.  The  result  has  been 
the  possibility  for  the  first  time  of  tracing  the  different  movements  and 
gradual  progress  of  the  plague,  and  with  it  certain  features  in  the  epi- 
demiology of  plague  have  become  conspicuous.  These  are  the  slowness 
of  the  progressive  advance,  the  evident  difficulty  with  which  new  centres 
are  formed,  and  the  absence  at  present  of  any  special  tendency  to 
severe  epidemics.  They  are  features  probably  not  new  to  plague,  for 
they  are  likely  to  have  been  overlooked  at  earlier  periods  when  the 
facilities  for  obtaining  information  were  less  than  they  are  now.  If 
it  be  true  that  plague  has  generally  such  a  vanguard  of  sporadic  cases 
when  spreading  in  pandemic  form,  these  sporadic  cases  may  be  the 
missing  links  which  are  so  frequently  wanting  in  tracing  the  connection 
between  concurrent  epidemics  in  widely  separated  places. 

There  is  one  noticeable  feature  belonging  to  the  existing  pandemic 
and  which  presages  danger  in  the  future.  It  is  that  notwithstanding 
its  apparent  inability  to  cause  in  any  one  place  a  great  epidemic,  it 
exhibits  in  some  places  marvellous  powers  of  recrudescence  and  re- 
sistance to  all  known  measures  of  prevention,  and  this,  even  when  the 
cases  are  few.  This  tenacious  capacity  combined  with  its  transporta- 
bility makes  it  formidable  because  its  slow  progress,  few  cases,  and 
possibly  slight  mortality,  accustom  the  people  to  its  presence,  and  lull 
the  authorities  into  a  frame  of  mind  of  looking  upon  it  as  a  very 
manageable  disease.     In   the   meantime   it    gradually  dots    itself  over 


CH.  vii]  Danger  of  existing  Pandemic  145 

different  parts  of  the  country,  securing  a  firm  hold  in  some  localities 
which  again  form  fresh  centres  for  its  activity,  until,  in  the  course  of 
a  few  years,  it  is  fairly  established  in  the  country  at  many  centres,  and 
only  awaits  the  conditions  necessary  for  its  development  into  an  alarming 
epidemic.  In  this  respect  its  behaviour,  when  established  in  a  country, 
is  likely  to  be  similar  to  small-pox  in  an  unvaccinated  country  in  which 
there  are  a  series  of  years  with  a  few  cases  followed  by  one  or  two 
epidemic  years.  In  Africa  and  South  America  the  dotting  stage  appears 
to  be  in  progress. 

The  danger  of  the  existing  pandemic  lies  not  so  much  in  its  present 
aspects  with  its  slight  diffusive  powers,  but  in  the  oppor- 
the  existing        tunities  which  it  may  meet  with  of  acquiring  both  virulence 
pan  emic.  ^^^  diffusive   qualities.     Such   opportunities   would  arise 

in  the  case  of  distress  on  a  large  scale  from  economical  or  political 
causes,  from  atmospheric  conditions  giving  rise  to  scarcity,  or  from  war. 
None  of  these  will  themselves  give  rise  to  plague,  but  with  plague 
spreading  as  at  present,  any  one  of  them  would  serve  to  render  it 
formidable. 

It  is  because  of  these  dangers  that  the  plague  in  India  with  its 
extensive  area  of  infection  may  at  any  time  become  a  menace  to  Europe, 
for  it  possesses  all  the  potentialities  which  once  developed  would  give 
it  those  diffusive  qualities  that  have  characterised  former  pandemics. 
It  has  at  present  reached  Cashmere  and  is  not  far  from  the  borders  of 
Afghanistan.  Should  it  attack  and  pass  through  the  latter  country, 
it  then  reaches  the  high  road  through  which  so  many  epidemics  have 
entered  Russia  and  Europe.  There  is  always  the  possibility  of  the 
plague  in  India  assuming  the  influenza  type,  and  should  this  ever  occur 
then  there  is  nothing  to  prevent  a  repetition  of  the  ravages  that  plague 
committed  in  the  sixth  and  fourteenth  centuries. 

From  an  epidemiological  point  of  view  there  are  two  varieties  of 
plague.  Between  them  are  plagues  which  approximate  more  to  the  one 
or  to  the  other  variety.  The  first  and  the  most  common  is  that  which 
frequents  the  more  or  less  endemic  areas  and  their  neighbourhood,  with 
small  tendency  to  spread.  It  may  possess  considerable  powers  of  ex- 
tension once  it  has  passed  beyond  the  bounds  of  the  endemic  area,  but 
it  seldom  displays  any  great  contagious  qualities,  most  frequently  re- 
taining the  characters  of  its  origin.  The  second  is  on  the  other  hand 
a  plague  of  an  expansive  and  diffusive  character,  manifestly  contagious 
both  to  man  and  to  many  kinds  of  the  lower  animals,  and  is  capable 
of  causing  wide-spread  destruction  to  both. 

s.  10 


146  Epidemioloffy  of  Plague  [part  ii 


PLAGUE   EPIDEMICS   AND   SEASONAL   INFLUENCES. 

The  season  of  the  year  has  a  very  powei-ful  influence  on  the  pre- 
Piague  epi  valence  of  plague  and  the  duration  of  the  epidemic.    There 

demies  occur  lYoxy  be  in  any  locality  a  few  cases  of  plague  all  the  year 
seasons  of  the  round,  for  instance  in  Bombay  and  in  Hongkong  there  is 
y®^-  not  a  month  without  a  case,  but   it   is  only  at   certain 

seasons  that  the  disease  becomes  epidemic.  This  season  may  vary 
somewhat  in  different  localities,  but  it  is  nearly  always  the  same  in 
the  same  locality,  and  has  a  tendency  to  become  earlier  the  further 
south  it  occurs.  Plague  may  occur  in  endemic  centres  such  as  in  the 
mountainous  regions  of  Assyr  or  Kurdistan  under  conditions  of  intense 
cold ;  but  intense  cold  or  intense  heat  are  generally  inimical  to  the  rise 
of  an  epidemic,  though  they  do  not  prevent  the  occurrence  of  sporadic 
cases  even  outside  the  endemic  areas,  when  these  sporadic  cases  are  the 
remnants  of  a  preceding  epidemic  or  the  harbingers  of  one  that  is 
impending.  An  occasional  outbreak  of  pneumonic  plague  such  as  the 
Vetlianka  outbreak  may  take  place  in  the  depth  of  a  severe  winter,  but 
it  is  seldom  of  any  great  dimensions.  Similarly  small  epidemics  have 
occurred  in  Sindh  with  a  temperature  of  between  110^  F.  and  120"  F., 
but  they  are  exceptions. 

The  development  and  decline  of  the  epidemic  of  plague  m  Bombay  in 
1806  are  shown  in  Diagram  A  on  the  next  page,  taken  from  the  report  of 
the  Health  Officer  on  the  outbreak,  and  is  an  excellent  t^-pe  of  the  usual 
characters  of  most  great  epidemics  of  plague.  First  of  all  there  is  a 
period  of  hesitancy  more  or  less  prolonged ;  then  there  is  a  sudden  but 
fluctuating  rise  which  reaches  its  highest  point  in  the  course  of  three 
months  or  in  a  shorter  time  ;  and  then  there  is  a  decline  possessing 
much  the  same  character  as  the  ascent  but  often  less  prolonged ;  and 
finally  the  disease  lingers  in  a  sporadic  form  for  some  months. 

The  duration  of  any  of  these  stages  may  vary  somewhat,  being 
either  lengthened  or  shortened,  so  that  within  the  plague  season  there 
may  be  epidemics  lasting  from  4  to  8  months.  If  the  epidemics  them- 
selves were  anal3-sed,  they  would  be  found  to  be  more  or  less  a  series 
of  epidemics  invading  at  different  times  different  districts  of  the  same 
city.  The  months  of  epidemic  prevalence  in  several  towns,  the  month 
in  which  the  epidemic  reached  its  maximum  and  the  duration  of  the 
epidemic,  are  shown  in  Diagram  B  on  page  148. 


Diagram  A. 

Weekly  Total  and  Average  Mortality. 


\?c^U 


WEEK       ENDING 

JUN 

E'JUL 

I  Aug.iSep 

Oct 

Mny  Dec.  Jan 
°^-18961897 

Feb 

Mar.  Apr 

1 

May 

1  900 

1,850 

i,snn 

• 

Plague 

MORTALn 

Weekly 

MORTALI 

■Y 

-•— 

} 

S 

1,750 
1,700 
1,650 

Total 
rY .« 

11  ? 

Weekly  ■Average 

MOBTAr  ITY                           , 

•  1  r 
ii  il 

•  • 

1  600 

jHT 

•     1 

1,550 
1,500 
1  450 

■ 

1 

• 

1,400 

• 
1 

1 
! 

1  350 

i 
i 

1,300 
1,250 
1,200 

1,150 
1  100 

! 

} 

1 

i 

• 

r 

- 

850 
800 
750 
700 

\ 

1,050 

11 

1 

A 

1 

i 

950 

\ 

\ 

• 

900 
850 
800 

650 
600 

'i>>n 

750 

500 
450 

• 

a 

W 

.1 

i 

700 

1 

• 
1 

i 

i 

1 
• 

t . 

lil 

r 

\ 

/ 

1 

if 

i 

f 

1 

1  \ 

Rnn 

4qo 

3.4o 

i/ 

ir 

i  / 

m 

U 

• 

\j 

• 

'a 

550 

• 

M' 

;i' 

/ 

• 

• 

\ 

Ah 

i\ 

500 

7 

V^ 

• 

r 

1/ 

•■• 

\ 

/ 

\ 

Ai 

M 

.VI 

I 

100 

t 

\ 

M, 

u- 

v 

0 

J^ 

10—2 


148 


EpiclemtohKHi  of  Plague 
Diagram  B. 


[part  II 


Duration  of  Epideviics  and  Months  of  their  greatest   Intensity  in 
different  Localities. 


Name  of  Locality 
Moscow  1771—77 
London  1665—66 
Marseilles  1720 
Dantzic 
Oporto 
Aleppo 
Alexandria 
Karachi  1896-97 
1897—98 
1898—99 
1899—1900 
1900—01 
Hongkong  1894 
1896 
1898 
1899 
1900 
1901 
1902 
Bombay  1896—97 
1897—98 
1898—99 
1899—1900 
1900-01 
Mauritius 
Cape  Town 
Sydney 
Brisbane 
Pernambuco 


Oct 

Nov 

Dec 

Jan 

Feb 

Mar 

Apl 

May 

Jun 

Jul. 

Au(| 

Sep 

Oct  1  Nov 

Dec 

Jan 

Feb 

Mar 

V 

V 

_i^_ 

r?c^ 

Y 

Vf 

Y 

A 

V 

Y 

V 

V 

A 

V 

A 

v 

A 

Y 

V 

•J 

A 

V 

Y 

Y 

A 

Y 

V 

V 

Y 

A 

V 

A 

A 

' 

; 

^ 

1 

V 

X 

\j 

X 

V 

A 

In  Europe  great  epidemics  occur  in  sumnier  and  autumn,  the  worst 
months  being  usually  August  and  September.  In  London  the  epidemics 
of  1603, 1605,  1625,  1636,  and  1665  resembled  one  another  in  beginning 
in  June  and  ending  in  J)ecember,  the  greatest  number  of  deaths  being 
between  the  latter  part  of  July  and  the  end  of  September.  In  Marseilles 
the  epidemic  of  1720  took  a  similar  course,  beginning  in  June  and 
declining  rapidly  at  the  end  of  September.  In  Moscow  the  epidemic 
of  1770  raged  from  April  to  December,  but  by  far  the  worst  month  was 
September,  when    21,000   deaths   were   recorded.     In  Asia  Minor  the 


CH.  VIl] 


Seasonal  Influences 


149 


epidemic  season  is  generally  sj)ring  and  summer.  The  Syrian  epidemics 
usually  began  in  March  or  April  and  ended  in  August,  the  worst  month 
being  June.  The  Egyptian  epidemics  generally  commenced  in  December 
or  January  and  terminated  in  June  or  July,  the  highest  mortality  oc- 
curring in  March  or  April.  At  other  periods  of  the  year  the  disease 
was  more  or  less  quiescent,  the  last  half  of  the  year  having  comparatively 
few  cases.  Recent  epidemics  in  Egypt  have  shown  similar  seasonal 
characteristics.  In  Hongkong  plague  prevails  epidemically  in  the  late 
spring  and  summer  and  reaches  its  height  in  May  or  June. 


Jan. 


Diagram  C. 

Chart  showing  the  mortality  from  the  Plague  for  the  year   1903 
compared  with  the  average  of  the  previous  5  years. 

Feb.  March        April  May  .June  July  August  Sep.  Oct.  Nov. 


Dec. 


In   India    there    may  be    two  epidemic    seasons:    one    in   January, 
February  and  March,  and  another  in  August,  September,  October  and 


150  F^ndemiologt/  of  Plague  [part  ii 

November.  In  Bombay  plague  prevails  from  October  or  November  to 
May  or  June  and  reaches  its  height  in  February  or  March.  In  Calcutta 
it  prevails  a  little  later  than  in  Bombay  and  reaches  its  height  in 
March  or  April.  The  seasonal  occurrence  of  plague  in  Calcutta  is 
shown  in  the  Diagram  C  taken  from  the  report  of  the  Health  Officer 
for  Calcutta  for  the  year  1903. 

On  the  other  hand  the  epidemics  at  Poona  have  been  later  in  the  year. 

In  the  Mauritius  it  is  epidemic  from  July  to  March,  arriving  at  its 
climax  usually  in  October  or  November.  In  the  southern  hemisphere 
epidemics  manifest  themselves  during  the  first  half  of  the  year.  In 
Cape  Town  plague  was  epidemic  from  February  to  June,  being  worst 
between  the  end  of  March  and  the  first  weeks  of  April.  It  was  much 
the  same  in  Brisbane  and  in  Sydney,  where  the  plague  was  first  detected 
towards  the  latter  part  of  February ;  and  continued  epidemically  until 
the  end  of  June.     Its  worst  period  was  in  April. 

The  range  of  temperature  favourable  to  plague  varies  considerably 

in  different  localities,  the  most  favourable  being  between 

affects  the  ^^°  ^-    ^^^    ^^°  ^- '     mean    temperatures    above    85°  F. 

endemicity  ^nd  below  50°  F.  are  as  a  rule  unsuitable  for  epidemic 
of  plague.  .  .  . 

prevalence.     In  the  Hongkong  epidemics  any  continuous 

temperature  above  83°  F.  is  followed  by  a  decline  of  the  epidemic  which 
does  not  begin  again  until  the  following  spring.  In  the  Bombay  epi- 
demic there  is  always  a  fall  when  the  mean  temperature  is  above  82°  F. 
and  sometimes  when  it  reaches  80°  F.  In  Cape  Colony  and  Sydney 
there  was  a  decline  when  the  temperature  lowered  to  a  mean  of  50°  F. 
The  maximum  temperature  in  the  latter  places  was  never  so  high  as  to 
check  the  rise  of  the  plague  once  the  disease  had  become  epidemic. 
Plague  prevailed  most  at  temperatures  between  55°  and  70°  F.  In  the 
Cape  it  was  observed  that  ten  days  to  a  fortnight  after  a  rise  in  the 
mean  temperature  there  was  an  increase  in  the  number  of  plague  cases. 

No  very  marked  influence  seems  to  be  exerted  by  rain.  If  any- 
thing, slight  rain  with  heat  appears  to  favour  plague,  whereas  heavy 
and  continuous  rain,  although  often  an  antecedent  of  a  plague  outbreak, 
seems,  on  the  other  hand,  when  plague  has  broken  out,  to  be  unfavourable 
to  its  epidemicity  especially  if  it  is  the  cause  of  large  floods.  It  may 
be  infected  rats  are  unable  to  escape  from  the  floods. 

Why  plague  is  so  strongly  controlled  by  seasonal  influences  is  one 
Season  a  com-  of  the  many  problems  still  to  be  solved.  Season,  Avith 
posite  force.  j^g  meteorological  factors,  is  a  composite  force,  and  as  such 
operates  in  more  than  one  way  on  the  agents  and  media  connected  with 


CH.  vii]  Seasonal  Influences  151 

plague.  For  instance  it  affects  a  man's  constitution  and  powers  of 
resistance  against  infective  diseases  in  various  ways  through  its  influence 
on  the  air,  soil  and  food  which  react  on  man ;  it  affects  the  plague 
bacillus  in  regard  to  reproduction  and  virulence,  and  it  affects  animal  and 
insect  life  as  well.  The  difficulty  lies  in  differentiating  the  main  factors 
of  which  season  is  composed,  and  in  determining  the  exact  influence  of 
each  on  man,  the  plague  germ,  and  on  animals  and  insects  concerned 
in  the  spread  of  plague. 

The  older  writers  observing  seasonal  variations  in  plague  were 
content  in  attributing  it  to  an  "  epidemic  constitution,"  and  did  not 
attempt  to  analyse  what  that  constitution  was.  We  are  no  further 
advanced  to-day  in  this  respect.  The  only  serious  investigation  into 
the  influence  of  different  climatic  factors  on  plague  is  that  carried  out 
Mr  Baldwin  by  Mr  Baldwin  Latham ^  He  found  no  particular  tem- 
anaivsis^of  perature  of  the  air  nor  temperature  of  the  ground  to  have 
the  influence  any  marked  connection  with  the  incidence  of  plague,  but 
factors  on  ^^^^  plague  prevailed  at  a  period  of  the  year  when  exhala- 

piague.  tions  from  the  ground  were  greatest,  and  ceased  at  a  time 

when  the  ground  exhalations  were  slightest.  Diagram  D  shows  the 
season  of  the  year  when  the  vaporous  exhalations  are  highest  and  lowest 
in  Croydon.  Comparing  these  with  the  weekly  number  of  deaths  from 
plague  in  London  in  the  years  1564,  1592,  1603,  1607,  1686,  1642,  and 
1665,  and  also  with  the  vaporous  exhalations  in  London  during  a  period 
of  15  years,  he  finds,  as  is  shown  on  the  diagram  on  page  152,  that 
there  is  a  strong  marked  parallelism  between  the  tensional  differences 
which  are  the  cause  of  vapours  rising  from  the  ground  and  the  plague 
epidemics  which  formerly  occurred  in  this  country. 

An  interesting  point  is  that  a  similar  investigation  into  the  tensional 
differences  in  Bombay  and  the  prevalence  of  plague  there  brought  out 
a  similar  result,  although  the  period  of  the  year  in  which  plague 
occurred  in  London  was  not  the  same  as  in  Bombay.  It  was  de- 
monstrated that  the  forces  that  gave  rise  to  earthy  exhalations  only 
came  into  operation  in  Bombay  as  in  London  at  the  particular  times 
that  the  plague  was  rife. 

Experimenting  with  cylinders  filled  with  earth  freely  suspended 
in  a  perforated  tube  within  the  earth,  at  depths  of  1  foot  and 
2    feet    below    the   surface,  it  was  ascertained  that    the    hygrometric 

1  "The  Climatic  Conditions  necessary  for  the  Propagation  of  Plague."  By  Baldwin 
Latham.  Quarterly  Jmtrnal  of  the  Royal  Meteorological  Society,  Vol.  xxxvi.  No.  118, 
Jan.  1900. 


152 


Ejndemialofjij  of  riagne 


[part  II 


condition  of  the  ground  varied  according  to  the  temperature  of  the 
air  and  the  temj)eratui-e  of  the  ground.  The  earth  cylinders  increased 
in  weight  when  the  air  was  warmer  than  the  ground,  and  lost  weight 
when  the  temperature  of  the  air  fell  below  that  of  the  ground,  or  in 
other  words  when  the  air  was  warmer  than  the  earth  condensation 
took  place,  but  when  the  earth  was  warmer  than  the  air  evaporation 
took  place. 

TENSIONAL  OirrERENCE   3-2FTGRbUND  AND   MEAN    OEW    POINT      CREENWICH 

Q9  0?  O;  HIN:  D?  0'.  

WCtKLr  TOTAL   DEATHS  1665 PLAGUE    DEATHS I66S    LONDON 

"'«o"      AVERAGE  TOTAL  DEATHS   I56*.  1592  .1603.  1608.  1636,  I642.»..,«.^  AVERAGE  PLAGUE  DEATHS   1564, 1532,1603.1808,1638. 16*2  — ._ 

TOTAL  r 
DCATHi 

8000 


6000 


4000 


2000 


The  periods  of  the  year  when  exhalations  escape  from  the  ground 
and  the  quantity  that  then  arises  were  then  determined.  Numerous 
observations  were  made  by  which  the  temperatures  of  the  ground 
at  different  depths  were  compared  with  the  temperatures  of  the  dew 
point,  and  the  factors  thus  obtained  were  employed  for  calculating  the 
tensional  difference  between  the  ground  air  and  the  temperature  of  the 
dew  point.  At  all  times  the  exhalations  take  place  in  proportion  to 
the  tensional  differences.  The  results,  as  stated,  compared  with  the 
period  of  the  year  of  plague  epidemics  in  Bombay  and  London,  showed 
that  the  rise  and  fall  of  the  tensional  differences  between  the  ground 
temperature  and  the  minimum  dew  point  agreed  in  a  remarkable 
manner  with  the  rise  and  fall  of  plague.  Mr  Baldwin  Latham  deduces 
from  his  observations  that  a  high  temperature  of  the  air,  by  raising  the 
temperature  of  the  dew  point,  and  causing  condensation  to  take  place. 


CH.  vn]  Seasonal  Influences  153 

stops  plague ;  while  a  fall  in  temperature  means  a  fall  in  temperature 
of  the  dew  point,  and  the  tensional  difference  between  a  low  dew  point 
and  a  high  ground  temperature,  which  would  at  once  lead  to  exhalations 
which  Mr  Baldwin  Latham  thinks  would  cause  liberation  of  plague 
bacilli  from  the  ground.  There  is  no  evidence  at  present  as  to  the 
possibility  of  plague  bacilli  being  lifted  from  the  soil  by  these  forces. 
The  facts  are  against  it,  but  the  question  needs  to  be  scientifically 
settled  by  experiment.  It  sounds  like  the  old  hypothetical  cause  of 
malaria  which  the  investigations  of  Laveran,  Ross,  Manson  and  others 
have  completely  destroyed.  If  the  vapours  have  any  influence,  it  is 
probably  in  the  direction  of  favouring  a  condition  productive  of  suscepti- 
bility of  the  organism  in  man  or  the  lower  animals  or  in  both. 

The  phenomena  observed  recently  of  strong  electrical  currents  in 
the  earth  disorganising  the  telegraph  service  indicate  that  the  con- 
ditions of  the  soil  are  influenced  considerably  by  meteorological  changes, 
and  that  the  conditions  of  the  soil  at  different  times  may  possess  power- 
ful properties. 

The  varying  hygrometric  condition  of  the  soil  and  its  fluctuating 

temperature    are  just   the  conditions  likely  to  affect  the 

condition  of        multiplication  and  possible  virulence  of  the  plague  bacillus. 

the  soil  and        ^^  ^|^g  same  time  they  may  exercise  a  ffreat  influence  on 

its  fluctuating  _  .  .  . 

temperature,       the  life  of  insects  which  may  carry  infection  to  and  between 

an  ^effect  on^^  animals  susceptible  to  plague  such  as  rats.  An  instance 
microbic  and  of  certain  seasonal  conditions,  bringing  into  activity  swarms 
of  insects,  is  to  be  seen  in  the  annual  but  sudden  ap- 
pearance of  green  flies  in  Calcutta  near  the  end  of  the  rains.  So  great 
is  their  number  that  for  several  nights  it  is  impossible  to  read  with 
comfort  except  under  a  mosquito  curtain.  They  get  into  the  food  and 
drink,  swarm  around  the  lamps,  and  it  is  impossible  to  be  comfortable 
for  the  few  nights  of  their  ephemeral  existence.  The  flies  disappear 
almost  as  suddenly  as  they  come.  They  are  the  harbingers  of  the  cold 
weather.  It  is  possible  that  insect  life  of  a  different  order,  useful  in 
assisting  the  spread  of  plague  by  acting  as  carriers,  may  be  brought  into 
activity  by  certain  conditions  of  the  soil.  In  relation  to  this  it  is 
interesting  to  note  that  Dr  TidswelP,  when  collecting  different  species 
of  fleas  infesting  rats,  had  no  difficulty  during  the  epidemic  of  plague  of 
finding  many  fleas  on  rats,  but  as  soon  as  the  epidemic  was  over  the 
rats  appeared  to  be  exceptionally  free    of  fleas.     The   egg,  larva  and 

1  "Ecto-paiasites  of  the  Eat."  By  Frank  Tidswell,  M.B.  Report  of  the  Board  of 
Health  on  a  second  outbreak  of  Placjiie  at  Sydney,  1902.  By  J.  Ashburtou  Thompson,  M.D., 
President. 


154  Epidemiology  of  Plague  [part  ii 

pupa  of  fleas  on  rats  are  probably  affected  in  their  development  by  the 
seasonal  temperature  and  moisture  of  the  soil,  which  vary  in  time  in 
different  places  but  recur  about  the  same  time  yearly  in  the  same  locality. 

That  a  mean  temperature  of  83°  F.  should  exert  so  marked  a  control 
over  an  epidemic  of  plague,  while  the  bacillus  flourishes  in  man  at 
98  F.  and  in  birds  at  107^  F.,  leads  one  to  suppose  that 
ture  of  the  the  influence  is  not  a  direct  one  on  the  plague  bacillus 
directly  In-  itself,  which  aj)pears  to  be  able  to  develop  at  considerably 
fluentiai.  higher  temperatures  than  83°  F.     Especially  is  this  view 

emphasised  when  it  is  considered  how  much  the  infection  is  a  house 
infection,  where  direct  sunshine  plays  a  very  unimportant  part,  the 
microbe  being  never  exposed  to  any  very  high  aerial  temperature,  or 
to  any  exceptionally  low  temperature  which  might  destroy  it. 

Connected  with  seasonal  influences  is  also  the  peculiar  fact  that,  on 

the  decline  of  an  epidemic,  infected  articles  and  houses  in 

^he*piague°       the  infected  locality  lose  their  power  of  infection  for  the 

season  infect-     time  beinsf,  until  the  favourable  season  comes  round  again. 

ed  articles  .  .  .  . 

lose  their  in-      The  best  examples  of  this  are  from  epidemics  belonging  to 

fectivity,  but      ^^   earlier  period  than   those   of  the   existing  pandemic, 

may  regain  it  i  r 

the  foUowing      because  the  latter  are  not  dissociated  from  active  measures 

for  the  suppression  of  the  disease.     The  fact  is,  however, 

discernible  in  all,  whether  old  or  recent.     In  the  plagues  of  London, 

Marseilles,  Naples  and  Egypt  the  inhabitants  who  fled  when  the  epidemic 

was  increasing  have  flocked  back  to  the  infected  houses  towards  the  end 

of  the  epidemic,  have  slept  in  infected  beds,  and  have  worn  the  clothes 

of  those  who  have  died  of  plague,  yet  beyond  a  number  of  accidents  here 

and  there  that  general  infection  which  was  to  have  been  feared  has  not 

taken  place ;  and  yet  when  a  recrudescence  takes  place  in  the  season 

of  the  following  or  a  subsequent  year,  the  infection  is  frequently,  as  in 

Hongkong  it  was  largely,  connected  with  plague  in  the  same  house  in 

the  previous  year  or  in  the  year  previous  to  that. 

That  healthy  persons  run  great  risk  of  contracting  the  disease  during 

the  epidemic  season  by  sleeping  in  beds  previously  occupied  by  plague 

patients  was  shown  in  Cairo  in  1835,  when  on  the  15th  of  April  two 

criminals,  Ibrahim  Assan  and  Ben  AH,  condemned  to  death,  were  taken 

from  the  citadel  in  Cairo  and  given  beds  to  sleep  in  which  had  been 

vacated   by  two  patients  suffering  from  well-marked  plague.     On  the 

19th  of  April,  Ibrahim  was  attacked  by  plague  with  bubo  and  carbuncle. 

He  died  on  the  23rd.     Ben  Ali  was  also  attacked  at  the  end  of  the 

3rd  day  with  the  ordinary  symptoms  indicating  the  invasion  of  plague, 

but  the  illness  aborted  and  convalescence  commenced  on  the  4th  day. 


CH.  vii]  Rapid  Loss  of  Infectivity  155 

The  rapid  loss  of  infection  at  a  time  when  the  plague  bacillus  is 

most  widely  distributed  in  a  town  is  shown  bv  the  following 
Instances.  .    "  .  .  " 

passage  in  Hodges'  Loimologia :  "  '  About  the  close  of  the 

year,  that  is  in  the  beginning  of  November,  people  grew  more  healthful 
and  such  a  different  face  was  put  upon  the  public  that,  although 
the  funerals  were  yet  frequent,  yet  many  who  had  made  most  haste 
in  retiring,  made  the  most  to  return  and  came  into  the  city  with- 
out fear;  insomuch  that  in  December  they  crowded  back  as  thick  as 
they  had  fled :  the  houses  which  were  before  full  of  the  dead  were  now 
again  inhabited  by  the  living ;  and  the  shops  which  had  been  most 
part  of  the  year  shut  up  were  again  opened,  and  the  people  again  cheer- 
fully Avent  about  their  wonted  affairs  of  trade  and  employ,  and  even, 
what  is  almost  beyond  belief,  those  citizens  who  were  before  afraid, 
even  of  their  friends  and  relations,  would  without  fear  venture  into  the 
houses  and  rooms  where  infected  persons  had  a  little  before  breathed 
their  last ;  nay,  such  comforts  did  inspire  the  languishing  people  and 
such  confidence,  that  many  went  into  the  beds  where  persons  had  died, 
even  before  they  were  cold  or  cleansed  from  the  stench  of  the  disease." 

It  is  not  that  some  of  the  people  so  exposed  to  infection  were  not 
attacked  but  the  vast  majority  escaped,  a  contrast  to  that  which 
happens  when  the  epidemic  is  raging.  Then  the  infected  house  is 
dangerous. 

The  arrival  in  Bombay  of  between  250,000  and  300,000  immigrants^ 
during  the  months  of  April,  May  and  June,  when  the  first  epidemic  was 
declining  exercised,  as  will  be  seen  from  the  chart  showing  the  fluctua- 
ting rise  and  decline  of  plague  and  the  general  mortality  of  Bombay,  no 
check  on  the  decrease  of  the  plague,  once  that  disease  had  commenced  to 
decline.  Although  the  majority  of  these  immigrants  were  people  who 
had  fled  from  the  city  when  plague  was  becoming  epidemic,  yet  a  large 
proportion  consisted  of  destitute  country  labourers,  who  had  flocked  into 
the  city  from  the  famine  districts  of  the  Presidency  in  search  of  work. 
Labour  was  scarce  and  the  price  of  grain  was  high.  Notwithstanding 
the  opening  of  relief  works  and  the  payment  of  those  put  on  to  them 
of  subsistence  allowance,  the  city  contained  a  large  number  of  feeble, 
half-starved  and  ill-fed  persons  who  crowded  into  houses  many  of  which 
had  been  declared  unfit  for  habitation.  In  spite  of  these  circumstances 
peculiarly  favourable  to  plague,  it   was   not  until   the  next  season   in 

'  Loimoloyia,  or  an  Historical  Account  of  the  Plariue  in  London  in  1665.  By  Nath. 
Hodges,  M.D.,  p.  27. 

"^  Report  of  the  Bombay  Plague  Committee  on  the  Plague  in  Bombay  for  the  period 
extending  from  the  1st  July,  1897,  to  the  30th  April,  1898. 


156  Epideinloloyij  of  Plague  [part  ii 

November  that  the  plague  once  more  began  to  show  signs  of  becoming 
epidemic.  The  disease  had  lost  the  infectivity  it  possessed  in  November, 
December,  January  and  February.  This  is  a  very  striking  feature  of 
plague,  not  explainable  by  lessened  opportunity  of  exposure  to  infection 
from  the  plague  bacillus  in  the  houses  or  in  the  sick  persons.  The 
microbe  is  able,  as  before,  to  develop  and  multiply  in  the  human  body 
if  once  introduced,  as  is  to  be  seen  by  the  residual  number  of  persons 
who  continue  to  be  atiected  with  plague,  but  there  is  some  important 
factor  or  factors  wanting  which  it  possessed  just  before,  and  endowed  it 
with  its  active  qualities  of  infectivity  and  extension. 

The  variation  in  power  of  infectivity  was  well  known  among  the 
inhabitants  of  the  Levant  and  Egypt,  and  the  Franks  or  merchants, 
taking  advantage  of  this  knowledge,  shut  themselves  up  in  their  houses, 
whenever  the  disease  began  to  show  signs  of  progress,  and  continued 
to  do  so  until  there  was  a  marked  decline  in  the  disease.  Little  dread 
was  felt  for  the  disease  when  it  arrived  at  the  more  or  less  sporadic 
stage. 

In  Cairo  the  plague  used  to  rapidly  decline  in  the  month  of  June, 
and  Russell,  in  some  criticisms  which  he  passes  on  the  observation  of 
Prosper  Alpinus  that  the  disease  then  suddenly  ceases,  remarks:  "'It  is 
agreed  by  all  that  about  the  24th  of  June,  at  Cairo,  there  is  a  remark- 
able sudden  alteration  in  the  contagious  property  of  the  plague,  as  well 
as  in  the  malignity  of  the  disease  itself  to  whatever  cause  it  is  to  be 
ascribed  " ;  and  "  the  second  part  of  Alpinus'  observation  that  at  the  same 
time  the  pestilence  ceases,  the  furniture  in  infected  houses  suddenly 
loses  all  powers  of  communicating  the  disease  to  the  inhabitants,  so 
that  health  and  tranquillity  are  at  once  restored  to  the  city,  agrees  in 
some  measure  with  the  general  experience  of  other  places  in  Turkey, 
where  it  is  well  known  houses  or  goods  undergo  little  or  no  purification ; 
but  this  is  to  be  understood  with  some  restriction." 

The  restriction  is  that  there  are  a  fair  number  of  exceptions.  For 
instance,  it  was  ascertained  that  those  taken  ill  at  the  close  of  the 
epidemic  of  1720  at  Marseilles  were  mostly  persons  of  the  lower  class 
who  had  rashly  exposed  themselves  in  handling  infected  goods  or  in 
communication  with  the  sick.  The  fact,  however,  still  remains  that  the 
infective  qualities  of  plague  rapidly  disappear  at  a  time  when  the 
bacillus  is  most  widely  distributed  over  the  locality  attacked.  The  loss 
of  infectivity  is  independent  in  a  large  degree  of  the  measures  taken  to 
destroy  the  bacillus.     The  behaviour  of  plague  in  this  respect  is  the 

1  A  Treatise  of  the  Plague.     By  Patrick  Kussell,  M.D.,  F.R.S.,  pp.  268,  269. 


CH.  Yii]  Rapid  Loss  of  Infectivity  157 

same  in  Canton,  where  no  special  purification  of  houses  and  household 
effects  is  carried  out,  as  in  Hongkong,  where  particular  attention  is 
paid  to  the  disinfection  of  the  premises. 

Referring  to  the  practice  of  the  Turks  and  Moors  in  Egypt,  Mr  Bruce 
in  his  travels  says:  "^The  Turks  and  Moors  are  known  to  be  pre- 
dictionists.... Secure  in  this  principle  they  expose  in  the  market-place, 
immediatel}'  after  St  John's  day,  the  clothes  of  the  many  thousands 
that  had  died  during  the  late  continuance  of  the  plague,  all  of  which 
imbibe  the  moist  air  of  the  evening  and  morning,  are  handled,  bought, 
put  on  and  worn  without  any  apprehension  of  danger,  and  though  these 
consist  of  cotton,  silk  and  woollen  cloths  which  are  stuffs  the  most  re- 
tentive of  the  infection,  no  accident  happens  to  those  who  wear  them 
from  their  happj^  confidence," 

A  very  different  picture  from  this  presents  itself  at  an  earlier  period 
when  blind  faith  in  inevitable  destiny  led  to  practices  during  epi- 
demics, not  only  in  their  stages  of  decline  but  also  in  their  stage  of  rise 
and  crisis,  which  were  most  disastrous.  It  was  not  uncommon  for 
Turks  to  use  immediately,  while  even  damp  with  the  death  sweat,  the 
clothes  and  linen  of  persons  dead  of  plague.  "If  it  be  God's  will  I  should 
die  of  plague  it  is  unavoidable,  if  it  be  not  his  will  it  cannot  hurt  me," 
represented  their  feelings  on  the  subject,  and  from  such  a  standpoint 
the  practical  effect  was  that  whole  families  were  exterminated.  The 
same  superstition  spread  to  Cairo,  and  took  such  firm  hold  there  that 
a  traveller  remarked  that :  "  Through  this  Turkish  belief  plague  occasion- 
ally rages  so  severely  at  Al  Cairo,  and  such  a  large  number  of  people 
fall  victims  to  it  that,  on  different  occasions,  over  500,000  persons  have 
died  of  this  fatal  disease  within  6  months^." 

A  similar  loss  of  infectivity  as  that  observed  with  plague  on  the 

decline  of  an  epidemic  was  noticed  in  Calcutta  at  certain 
The  same  ob-  .  .  ^, 

servation  has     seasons  of  the  year  m  regard  to  small-pox.      ihere  were 

^^^^^^f-*^®  ^^     cycles  of  four  or  five  years  in  which  there  was  a  rise  and  fall 

small-pox  of  small-pox,  and  it  was  noticeable  that  if  small-pox  was 

introduced  by  returning  pilgrims  from  the  Hedjaz,  as  it 

often  was,  while  the  disease  was  on  the  descent  no  precautions  were 

necessary  to  prevent  the  spread  of  the  disease.     A  case  of  small-pox 

might  be  in  a  building  with  a  hundred  others,  and  yet  at   the  "most 

there  might  only  be  one  or  two  infected,  but  more  frequently  none  at 

all,  notwithstanding  intimate  exposure.     While,  if  small-pox  was  on  the 

1  A  Treatue  of  the  PUigne.     By  Patrick  Russell,  M.D.,  F.Il.S. 

-  The  Great  Kpiileiuics  of  the  East  from  Arabian  Sources,  p.  30.     Kremer. 


158  Epidemiology  of  Plague  [part  ii 

upward  grade,  the  danger  to  the  inhabitants  was  very  gi-eat  if  the  case 
was  not  immediately  isolated.  The  same  observations  were  made  with 
reference  to  the  infectivity  of  vaccine.  During  the  spring  children  and 
calves  showed  beautiful  vesicles  on  the  vaccinated  parts,  while  in  the 
rainy  season  there  was  the  utmost  difficulty  in  maintaining  the  vaccine 
of  either  children  or  calves,  the  vesicles  showing  signs  of  degeneration 
from  the  normal,  and  the  lymph  not  taking  when  transferred. 

The  regularity  in  the  seasonal  periodicity  of  plague  in  an  infected 
locality  has  been  attempted  to  be  explained  by  the  seasonal 
perio^city  of     breeding  period  of  the  rat.     Gotschlich,  in  discussing  this 
plague,  and        subject  as  regards  Egypt,  points  out  that  there  are  two 
breeding  types  of  plague  prevalence  in  that  countiy,  the  winter  or 

period  of  the  pneumonic  type,  due  to  infection  from  individual  to  in- 
dividual, and  the  summer  or  bubonic  type,  due  to  rat 
infection.  The  bubonic  form  according  to  this  observer  is  always  the 
initial  disease  in  man,  the  primary  pneumonic  arising  in  the  course  of 
an  epidemic  from  secondary  plague  pneumonia  in  a  bubonic  case.  In 
examining  6500  rats  in  the  course  of  a  year,  Gotschlich  found  from 
November  to  February,  i.e.  during  the  plague-free  winter  months,  that 
only  2  ^0  of  the  rats  Avere  pregnant ;  in  March  and  the  first  half  of 
April  there  was  a  gradual  rise,  reaching  in  the  second  part  of 
April  6  7„,  and  to  12  ^o  by  the  middle  of  Ma}^  after  which  there 
was  a  rapid  fall,  the  percentage  being  at  the  end  of  September  5  "/o 
and  in  October  2  "/o-  It  was  also  observed  that  in  the  plague-free 
months,  many  of  the  older  rats  suffered  from  a  latent  or  chronic  form 
of  plague,  while  when  the  younger  rats  came  into  existence  these  young 
rats  were  susceptible  to  the  acute  diseased 

^  Neue  epidemiologische  Erfahrungen  iiber  die  Pest  in  Aegypten  von  Prof.  Dr  Emil 
Gotschlich.     Festschrift  zum  sechzigsten  Geburtstage  von  Robert  Koch,  1903. 


CHAPTER   VIII. 

VARIATION   IN   VIRULENCE   OF   PLAGUE   EPIDEMICS. 

A  GREAT  mortality  in  a  country  may  not  be  synonymous  with  virulence; 
for  example,  the  epidemic  of  Egypt  of  1834-35,  though  it  caused  some 
50,000  deaths  from  plague  in  the  country,  had  an  average  case  mortality 
of  about  33  per  cent.,  contrasting  in  this  respect  with  some  of  the  earlier 
epidemics,  when  it  was  nearer  70  per  cent.  A  comparison  of  epidemics 
of  plague  with  each  other  shows  that  no  standard  can  be  equally  applied 
Variation  in  to  all,  for  they  differ  very  considerably  in  their  respective 
virulence.  severity,  some  epidemics  being  remarkably  benign,  others 

extremely  malignant,  and  between  these  extremes  there  is  every  variety 
approximating  more  or  less  to  one  quality  or  the  other.  Nor  is  the 
difference  in  type  peculiar  only  to  different  epidemics,  for  the  same 
epidemic  may  be  at  one  stage  malignant  and  at  another  mild. 

The  attention  which  malignant  plague  epidemics  attract  almost 
excludes  the  consideration  of  mild  epidemics,  and  yet  the  latter  are 
equally  important  from  an  epidemiological  point  of  view,  for,  as  will 
be  seen  later,  the  mild  may  develop  gradually  or  suddenly  into  the 
severe,  and  the  severe  attenuate  into  the  mild.  Great  epidemics  and 
high  mortality  are  so  written  into  the  history  of  plague,  that  it  is 
difficult  to  realise  they  are  the  history  only  of  great  epidemics,  and  that 
the  disease  may  be  associated  Avith  neither  of  them.  The  most  con- 
Mild  epidemic     spicuous  outbreak  of  plague  of  a  mild  nature  on  record  is 

of  plague  at  that  which  occurred  in  the  Delta  of  the  Volga  in  the  city 
Astrakhan  .  .  .  ^        f_i_ 

and  Vetii-  of  Astrakhan  and  its  environs  in  the   summer  of  1877  ^ 

^"^^  Some  200  persons  were  attacked  and  only  one  died.     The 

symptoms  were  malaise,  fever,  sometimes  acute,  running  in  a  few  cases 

to  as  high  as  104°  F.,  and  swellings  of  the  lymphatic  glands  in  the  neck, 

^  Ninth  Report  of  the  Local  Government  Board,  1879-80.  Supplement  by  the  Medical 
Officer,  p.  49. 


160  Epidtiii'ioloijii  of  Plcujue  [part  ii 

groin  or  arm-pit.  The  swellings  ended  either  in  resolution  or  suppura- 
tion. When  the  glands  began  to  swell  the  indisposition  usually  dis- 
appeared, the  appetite  and  general  functions  of  the  body  became  normal, 
and  the  patient,  except  for  the  swelling  impeding  motion,  was  rarely 
disabled  and  prevented  from  going  about.  The  cases  ran  a  course  of 
from  10  to  20  days,  sometimes  longer.  The  disease  seems  to  have  re- 
curred in  the  summers  of  1878  and  1879,  but  there  are  no  details  given. 
This  epidemic  would  never  have  attracted  special  attention,  had  it 
not  been  followed  in  the  autumn  of  1878  by  a  severe  outbreak  of  plague 
at  Vetlianka,  a  Cossack  settlement  higher  up  the  Volga  in  the  province 
of  Astrakhan.  The  outbreak  is  notable  for  its  malignity,  and  for 
the  alarm  which  it  caused  in  Europe.  Malignity  did  not,  however, 
characterise  its  commencement.  From  October  to  the  middle  of 
November,  the  malady  presented  similar  symptoms  to  the  non-fatal 
outbreak  in  the  city  of  Astrakhan,  viz.  fever,  slight  but  debilitating,  and 
glandular  swellings.  Dr  Doppner,  who  saw  the  cases  at  the  beginning 
of  November,  states  that  they  were  marked  by  two  or  three  paroxysms 
of  shivering,  and  succeeded  by  a  hot  stage,  and  by  swellings  of  the 
inguinal  and  axillary  glands,  often  ending  in  suppuration.  The  sick 
persons  were  afoot  with  good  appetites,  the  organic  functions  un- 
disturbed, and  sleeping  well.  They  had  abscesses  of  the  lymphatic 
glands,  either  of  the  groin  or  the  arm-pit,  which  were  suppurating  freely. 
The  duration  of  the  sickness  was  from  10  to  20  days,  and  all  the  cases 
recovered.  In  the  middle  of  November  a  second  phase  in  the  disease 
TheVetUanka     manifested    itself,  and   the   symptoms   became   so  violent 

outbreak  sud-     that  they  proved  fatal  in  from  12  hours  to  three  days.    From 

denly  ac-  t  w  i  . 

quires  great       ^November  27th  to  December  9th  of  100  persons  attacked 

virulence.  43  j-^^j  .^^d  14  recoveredi.     From  the  9th  of  December 

the  malady  became  more  acute.  New  patients,  whose  general  state 
appeared  good,  were  seized  with  violent  palpitation  of  the  heart,  a  pulse 
that  could  not  be  counted,  vertigo,  praecordial  anxiety,  haemoptysis, 
and  vomiting  of  liquid  uncoagulated  blood.  The  face  was  pale,  expres- 
sion apathetic,  and  eyes  heavy  and  sunk,  with  dilated  pupils.  In  the 
course  of  a  few  hours  extreme  prostration  supervened,  violent  feverishness 
set  in  with  somnolence,  slight  delirium,  constipation  and  suppression  of 
urine.     Fnjm  the  10th  of  December  were  added  to  these  symptoms,  in 

1  Keport  of  Dr  Doppner,  the  Principal  Medical  OflScer  of  the  Cossack  troops  in  the 
Province  of  Astrakhan  on  the  outbreak  of  Plague  in  Vetlianka  in  November  and  December 
1878.  Ninth  Ainitial  Report  of  the  Local  Government  Board,  1879-80.  Supplement  by 
Medical  OJicer,  p.  52. 


CH.  viii]  The  Vetlianka  Outbreak  161 

some  cases,  spots  upon  the  skin  varying  in  size  from  a  millet  seed  to 
a  ten  copec  piece ;  the  patients  exhaled  a  peculiar  odour  like  honey, 
became  collapsed  and  died  during  a  state  of  lethargy.  There  was  no 
mgor  mortis,  and  decomposition  set  in  at  the  end  of  two  or  three  hours. 
From  the  9th  of  December  the  rate  of  mortality  increased  from  day 
to  day,  and  on  the  14th  of  December  every  person  attacked  died. 

In  the  Vetlianka  outbreak  it  is  evident  that  a  transformation  had 
taken  place  from  a  mild  bubonic  form  of  plague  to  the  septicaemic  and 
pneumonic  varieties,  the  symptoms  being  those  that  are  to  be  recognised 
in  patients  suffering  from  these  types  of  the  disease  in  the  existing 
China  epidemic.  There  was  in  the  Vetlianka  outbreak  a  gradual  ascent 
from  the  non-fatal  cases  of  Astrakhan  to  the  bubonic  form  of  plague, 
more  or  less  malignant,  which  in  turn  reached  the  septicaemic  and 
pneumonic  type.  It  is  possible  that  the  pneumonic  cases  first  showed 
themselves  as  secondary  pneumonias  in  bubonic  cases  and  that  these 
secondary  pneumonias  gave  rise  by  their  infective  sputum  to  the  con- 
tagious primary  pneumonic  type.  Plague  of  this  malignant  type  is  rarely 
accompanied  by  buboes,  and  accordingly  it  is  not  surprising  that  some  of 
the  medical  men  were  inclined  to  think  that  the  latter  manifestations  were 
not  plague,  but  typJioid  pneumonia  or  typhus  complicated  with  pneumonia. 
It  was  only  in  1897,  during  the  first  epidemic  of  plague  in  Bombay,  that 
the  pneumonic  form  of  plague,  the  most  fatal  of  all  forms,  was  clearly 
ditferentiated  by  Dr  Childe  of  the  Indian  Medical  Service.  In  addition 
to  a  description  of  its  symptoms  and  of  its  pathological  appearances  he 
showed  the  sputum  of  the  patient  suffering  from  it  to  be  filled  with 
plague  bacilli,  and  the  disease  to  be  extremely  contagious.  It  was  not 
the  first  time  the  pneumonic  form  of  plague  had  been  recognised.  Guy 
de  Chauliac  of  Avignon'  in  1348  described  the  epidemic  of  plague 
which  ravaged  Avignon  as  consisting  of  two  types.     The  first,  the  most 

malignant  and  contagious,  prevailed  during  the  first  two 
lignity  of  tbe  months.  The  symptoms  were  constant  fever,  cough,  and 
dIm^°of  1348  spitting  of  blood,  the  illness  ending  fatally  in  three  days, 
with  its  pneu-  The  second  caused  no  symptoms  of  spitting  of  blood,  but 
toms  followed  buboes  appeared  in  the  groin,  under  the  arm,  or  in  the 
by  a  less  ma-      neck,  and  the  patient  gradually  succumbed  on   the  fifth 

day.  The  second  type  seems  only  to  have  been  observed 
two  months  later  than  the  pneumonic  type,  and  appears  to  have  lasted 
five  months.  In  this  instance  it  was  an  attenuation  or  decrease  of  the 
virulence  and  not  a  development  or  augmentation  as  in  the  preceding. 

'  La   Grande   Cliirurgie  de   Maixire    Guy  de   Chauliac.     Par  M.  S.   Miugelon   Saule, 
Traits  ii.  cap.  v. 

S.  11 


162  Epidemiolofiy  of  Plague  [part  ii 

Different  types  with  varying  degrees  of  virulence  may  be  seen 
running  concurrently  or  following  one  another  in  the  same  epidemic. 
At  Kathiawar  in  1820  pneumonic  plague  and  ambulant  plague,  which 
is  generally  the  mildest  form  of  plague,  were  observed  in  the  same 
epidemic.  Dr  Whyte  \  in  writing  of  the  varieties  of  plague 
types  with  which  he  and  Dr  Gilder  met  with  in  the  outbreak  of  plague 
grees°o^  viru-  '"  Kathiawar  in  1820,  describes  the  pneumonic  form  as 
lence  may  be  follows :  "  The  characteristic  symptoms  of  this  variety  are 
concurrently  slight  cough,  pain  of  the  chest,  and  haemorrhage  from 
or  following  ^j-jg  ^uouth  attended  with  fever,  but  with  no  buboes."  He 
one  another  .  -i  i    i     i        • 

in  the  same        also   mentions  a  mild   bubonic   variety ;    he   saw   a  great 

epidemic.  number  who  had  buboes  without  any  fever,  and  was  told 

that  upwards  of  a  hundred  and  twenty  had  suffered  in  this  way. 
"  These  people  walked  about  without  either  alarm  or  inconvenience, 
for  none  had  died  and  not  many  of  the  buboes  suppurated." 

Dr  Forbes-  in  his  account  of  the  Indian  epidemic  of  1836  in  which 
Four  different  plague  broke  out  in  Pali,  a  town  in  Marwar,  divides  the 
types  of  types  of  plague    seen  by  him  into  four  forms :   first,  an 

plague  in  the        -^  V  i     i        •  ii  •      i  i         ,  • 

Pali  epidemic      ordinary  bubonic ;  secondly,  a  more  virulent  and  malignant; 

of  1836.  thirdly,  a  most  fatal  pneumonic  in  which  there  was  scarcely 

any  febrile  excitement,  slight  cough  and  bloody  expectoration,  with 
oppression  at  the  praecordia  being  the  chief  symptoms ;  and  fourthly, 
an  extremely  mild  form  in  which  the  glandular  swellings  made 
their  appearance  with  little  constitutional  disturbance,  and  were  at- 
tended only  by  languor,  debility,  and  a  great  feeling  of  indisposition. 
In  the  latter  buboes  went  on  slowly  to  suppurate  and  health  was  only 
gradually  restored.  Dr  Forbes'  description  of  this  mild  form  is  similar 
to  that  given  by  Fodere,  as  applying  to  the  benign  plague  observed 
in  the  Levant  and  in  Marseilles  in  1.720,  and  concerning  which  Fodere 
declares  that  it  is  no  less  plague  than  the  other  forms,  and  equally 
demands  the  attention  of  the  physician  and  of  the  magistrates.  This 
plague  of  Marseilles  was  divided  into  five  classes  by  the  physicians 
Five  degrees  ^'^°  reported  on  it.  The  first  class  included  the  most 
of  severity  malignant  cases  ending  in  speedy  death,  and  was  observed 
Marseilles  specially  at    the    commencement    of    the    epidemic,    but 

epidemic  towards  the  end  there  was  observed  the  fifth  class  charac- 

oi  1720.  •       J    1        r  • 

tensed  by  few  signs  of  illness  and  ending  always  in  re- 
covery.    "  This  fifth  and  last  class  contains  all  such  infected  persons,  as 

1  Eeport  by  Dr  Whyte  to  the  Secretary  to  the  Medical  Board,  Bombay,  1820. 
*  Nature  and  History  oj  Plague  as  observed  in  the  North-lVest  Provinces,  by  Frederick 
Forbes,  A.M.,  M.D. 


CH.  Aaii]         The  Efjyptian  Aura  Pestilentiae  163 

without  perceiving  any  emotion,  or  there  appearing  any  trouble  or  lesion 

of  their  natural  functions,  have  buboes  and  carbuncles  which  rise  by  little 

and  little  and  easily  turn  to  suppuration,  becoming  sometimes  scirrhous, 

or,  which   is  more  rare,  dissipate  insensibly,  without  leaving  any  bad 

effect  behind  them  ;  so  that  without  any  loss  of  strength  and  without 

changing  their   manner   of  living,  these   infected   persons  went  about 

the   streets  and  public  places,  only  urging  themselves  a  simple  plaster, 

or  asking  of  the  physicians  and  surgeons  such  remedies  as  are  necessary 

to  these  sorts  of  suppurating  or  scirrhous  tumours'." 

Samoilowitz-,  in  his  account  of  the  plague  in  Russia  in  1771,  says 

the  disease  varied  according  to  the  stage  of  the  epidemic. 
Three  degrees  o        _  .  . 

of  severity  which  he  divides  into  three  periods  :  that  of  invasion,  that 
thrRussian  '^^  ^^^'^  middle,  and  that  of  the  end  or  decline.  The  milder 
epidemic  of  degree  of  the  disease  corresponded  with  the  period  of 
invasion,  in  which  the  patients  suffered  from  headache, 
vomiting,  and  buboes  which  suppurated.  Samoilowitz  saw  several 
persons  at  this  stage  who  recovered  without  medical  assistance.  Towards 
the  middle  of  the  epidemic  the  disease  assumed  its  most  terrible  and 
fatal  form.  Then  the  patients  had  carbuncles,  petechiae,  headache, 
delirium  followed  by  prostration,  constant  vomiting,  diarrhoea  and  in- 
continence of  urine.  Sometimes  it  was  impossible  to  stop  these  two  last 
excretions.  At  other  times  it  happened  to  women  that  the  menstrual 
How  could  not  be  stopped,  and  when  pregnant  they  miscarried,  the  orifice 
of  the  womb  relaxing  and  opening  with  ease.  On  the  decline  of  the 
epidemic  milder  cases  again  occurred,  similar  to  those  of  the  period  of 
invasion. 

In  the  epidemic  of  Cairo  in  1884  and  1885  investigated  by  Clot  Bey^ 

.     ,  Gaetani    Bey,  Lachese,   and   Bulard,  different   degrees  of 

An  Aura  .  .  . 

Pestilentiae        severity  of  the  disease  were  observed  at  different  stages  of 

Egyptian  ^^^  epidemic,  and  it  is  stated  that  the  great  majority  of 

epidemic  of        the  population  felt  the  influence  of  the  epidemic,  though 

1834-35.  ^    ^  1  o 

not  actually  attacked  with  plague.  Thus,  among  those 
suffering  from  the  Aura  Pestilentiae,  as  it  was  called,  painful  glands 
were  felt  in  the  groins,  or  arm-pits,  the  pain  being  usually  slight,  but 
increased  by  pressure,  muscular  contraction  or  movement  of  the  limbs, 

'  An  Account  of  the  Platiue  at  Marseilles,  its  symptoms,  and  the  methods  and  medicines 
used  for  curing  it.  By  MM.  Chieoyneau,  Verney,  and  Souillier.  Translated  from  the 
French  by  a  Physician.     London,  1721. 

-  Memoire  sur  la  Peste  qui,  en  1771,  ravaga  Vempire  de  Russie.     Paris,  1783. 

■*  De  la  Peste  obseriSe  en  Egypte.     Par  A.  B.  Clot  Bey. 

11—2 


164  Epiflemiolog}!  of  Plague  [part  ii 

and  appearing  or  disappearing,  to  reappear  again  w  ith  malaise,  want  of 

appetite,  white  tongue,  nausea  and  giddiness.     The  expression  of  the 

face  was  altered.     Those  who  were  thus  affected,  without  ceasing  from 

their  business,  were  not  infrequently  in  danger  of  being  attacked  with 

the  disease. 

In   the   first  variety  of  the  disease  which  was  encountered   in  the 

Three  degrees     middle,  and  especially  in  the  decline,  of  the  epidemic,  in 

of  severity  in      addition  to  the  phenomena  belonging  to  the  Aura  Pesti- 

the  Eg-yptian  ^  ... 

epidemic  of        lentiae,  there   were    observed    slight    fevenshness,   frontal 

^®^*  ^^-  headache,   altered    expression    of  the  face,  nausea,  which 

was  sometimes  followed  by  vomiting,  and  buboes  and  superficial  car- 
buncles, which  appeared  together  or  one  after  the  other  in  different 
glandular  regions.  The  buboes  terminated  by  resolution,  suppuration, 
or  induration.  The  patients  seldom  took  to  bed,  the  perspiration  was 
easily  established,  and  the  termination  was  never  fiital. 

The  second  variety  was  characterised  by  shivering,  vertigo,  headache, 
depression  more  or  less  profound,  general  lassitude,  staggering  gait,  as  if 
intoxicated,  lumbar  pains,  dazed  condition,  dull  gaze,  injected  eyes,  em- 
barrassed speech,  fi'equent  respirations,  nausea,  vomiting  of  mucous  and 
bilious  matter,  which  sometimes  and  at  a  more  advanced  stage  was 
blackish,  with  oi-  without  heat  of  skin,  frequent  pulse,  sometimes 
delirium,  tranquil  or  agitated,  restless  and  tiresome  dreams,  slight  pain 
in  epigastrium,  moist  tongue  with  white  fur  and  red  at  tip  and  edges, 
becoming  after  the  second  or  third  day  dry  and  red,  or  black  in  centre,  and 
cracked,  fuliginous  teeth,  diarrhoea  sometimes  declaring  itself  after  the 
first  vomiting,  and  the  urine  red,  sometimes  with  blood,  and  diminishing 
towards  the  end,  even  becoming  suppressed.  On  the  second  or  fourth 
day  this  variety  was  distinguished  by  appearance  of  buboes  in  the  arm-pits, 
groin,  or  neck,  very  rarely  in  the  popliteal  space,  and  of  carbuncles  and  of 
petechiae,  continuous  delirium,  coma  and  death  on  the  fourth  or  fifth  day. 

On  the  other  hand  if  the  patient  improved  the  symptoms  lost  their 
intensity,  the  tongue  became  moist,  the  skin  soft,  the  pulse  stronger, 
the  buboes  went  on  to  resolution,  suppuration,  or  induration,  the 
carbuncles,  if  any,  stayed  their  necrotic  action,  the  petechiae  resolved 
themselves  in  the  manner  of  enchymoses,  and  the  patient  entered 
into  a  state  of  convalescence  on  the  sixth  or  eighth  day.  Sometimes 
the  illness  was  prolonged,  tiie  tongue  remained  dry,  red  or  swollen, 
its  centre  was  covered  with  a  blackish  coating,  the  teeth  became  more 
fuliginous,  the  abdomen  swollen  up,  diarrhoea  persisted,  the  motions 
were  foetid,  sweating  and  diyness  of  the  skin  alteraated,  the  pulse  was 


CH.  vni]  Febris  Interinittens  Bnhonica  165 

frequent  and  irregular,  sleep  was  disturbed,  sometimes  delirious,  the 
buboes  went  on  slowly  towards  suppuration,  and  when  it  occurred  it 
was  serous  and  foetid.  The  patient  became  convalescent  about  the 
fourteenth  or  twentieth  day,  or  the  symptoms  became  aggravated  and 
the  issue  was  fatal.  This  variety  predominated  towards  the  middle 
and  decline  of  the  epidemic. 

In  the  third  variety  there  was  an  exaggeration  of  all  the  preceding 
symptoms.  It  was  characterised  by  an  air  of  hebetude,  extreme  mental 
and  physical  prostration,  restlessness,  trembling,  pains  in  the  loins, 
almost  normal  heat  of  skin,  short  and  rapid  respiration,  quick,  small 
and  full  pulse,  moist,  large  and  bluish  tongue,  bilious  vomiting,  some- 
times black,  no  pain  in  epigastrium,  often  petechiae  of  dark  colour, 
stammering  speech,  wandering  delirium,  affected  intelligence,  extreme 
anxiety,  with  coma,  death  in  24  or  48  hours,  rarely  longer,  with  a  cyanosed 
aspect  and  without  pain.  If  the  patient  lived  beyond  this  period  there 
was  a  reaction.  The  pulse  became  stronger,  the  tongue  red  and  dry,  the 
skin  hot,  the  face  flushed,  the  eyes  injected,  and  towards  the  third  day 
there  was  an  eruption  of  buboes,  rarely  of  carbuncles.  Then  were  estab- 
lished some  chances  of  recovery,  and  the  patient  might  present  similar 
symptoms  to  those  at  the  termination  of  the  second  variety,  but  this 
termination  was  rare.  Buboes,  petechiae  and  carbuncles  may  be  absent 
in  this  variety.  This  form  was  found  during  the  first  months  of  the 
epidemic  almost  exclusively,  although  it  was  also  seen  at  every  stage. 

In  the  Marseilles  epidemic  of  1720,  and  the  Cairo  epidemic  of 
1834-35,  the  most  malignant  cases  occurred  at  the  commencement  of 
the  epidemic,  and  the  disease  became  milder  in  the  later  stages.  This 
is  usually  the  most  common  behaviour  of  an  epidemic,  but  is  by  no 
means  a  general  law,  for  exactly  the  opposite  sometimes  occurs,  the 
epidemic  beginning  with  mild  cases,  as  happened  in  the  Russian 
epidemic. 

Mild  cases  are  described  by  Dr  Dutheuil  as  occurring  sporadically 

Sporadic  ^^  Mesopotamia  during   the  years   1856-1867,  and  were 

cases  of  mild      generally    set   down    as    typhus    or    malarial    fever    with 

precede  glandular    swellings.       One    physician    proposed    to   give 

severe  epi-  them  the  name  of  bubonic  fever,  or  Febris  intermittens 
demies  of  .  i  i  • 

plague,  or  bubonica,  a  term  which   was  applied  also   to  the  earlier 

bridErTover        cases  of  plague  in  Bombay  because  of  their  comparative 

the  intervals        mildness. 

epi  emi   .  That  the  cases  in  Mesopotamia  were  not  typhus  nor 

malarial  fever  with  buboes,  but  mild  cases  of  plague,  was  shown  after- 


166  Epidemiology  of  Plague  [part  ii 

wards  by  the  investigations  of  Tholozan  and  Cabiadis.  The  mild  type 
of  plague  was  carefully  studied  by  Tholozan  in  regard  to  the  Persian, 
Mesopotamian,  and  Benghazi  outbreaks,  and  he  formed  the  opinion  that 
they,  by  their  sporadic  occurrence,  bridged  over  the  intervals  between 
different  epidemics.  In  writing  of  the  plague  in  Hiudieh  Tholozan 
remarks,  "It  was  a  question  here  of  a  severe  bubonic  plague  which 
destroyed  in  several  months  about  the  third  of  the  population  of  the 
encampment  attacked.  I  do  not  speak  of  light  sporadic  cases  of  bubo 
without  fever  which  manifested  themselves  in  1856,  1858,  1859,  1860, 
1861, 1864,  and  1865.  One  of  our  distinguished  colleagues,  Dr  Batailly, 
saw  at  Bagdad,  in  the  spring  of  1867,  a  great  number  of  buboes,  especially 
inguinal  and  almost  always  without  fever,  which  lingered  on  till  autumn. 
Other  observers,  especially  Dr  Colville,  have  recognised  the  same  fact. 
At  Hillah  two  military  doctors  declared  that  at  this  time  the  buboes 
prevailed  in  the  regiments,  and  that  they  had  never  given  rise  to  any 
case  of  death.  Dr  Dickson  says  that  buboes  or  swellings  of  the  glands 
of  the  groin,  axilla,  or  neck  prevailed  in  the  whole  province  of  Bagdad 
in  the  spring  of  1867,  and  that  according  to  native  tradition  this 
frequency  of  buboes  indicated  the  appearance  of  plague.  At  this  time 
also  Dr  Palladin  observed  at  Divanie  spontaneous  buboes  in  the  groin 
of  two  soldiers,  a  gendarme  and  a  custom-house  officer.  The  four 
patients  recovered,  but  they  all  had  a  burning  fever,  a  vivid  thirst, 
a  slight  delirium  at  night,  and  diarrhoea.  Dr  Palladin,  who  com- 
municated these  facts  to  me  in  1870,  considered  them  then  as  cases 
of  plague.  It  may  be  contended  it  is  not  the  complete  plague,  but 
the  larval  or  embryonic  plague,  and  the  facts  demonstrate  the  slow  or 
gradual  preparation  of  the  illness  and  the  wide  primar}^  diffusion  of 
the  germs  ^" 

The  Mesopotamian  epidemic  of  plague  in  1876-77^  was  also  pre- 
ceded  hy  glandular  stuellings  free  of  fever.     The  swellings 
glandular  showed   themselves    in    the    groin,  arm-pit,  or  neck,  and 

blforrand  ^^'®^®  "^*  accompanied  by  other  symptoms.     They  began 

after  plague  to  appear  among  the  inhabitants  at  the  end  of  autumn, 
prev  e  e.  ^^^  continued  through  the  winter.  On  the  cessation 
of  fatal  plague  apyretic  glandular  stoellings  reappeared,  precisely  similar 
to  those  which  had  preceded  the  outbreak,  and  they  continued  to  mani- 
fest themselves  for  about  two  months  longer.    These  glandular  swellings 

^  La  Peste  en  Turquie,  Tholozan,  p.  86. 

2  "  On  the  character  of  epidemic  plague  in  Mesopotamia  in  1876-77."     By  E.  D.  Dickson, 
M.D.     Tramactions  Epidem.  Society,  Vol.  iv.,  1879. 


CH.  viii]  The  Naj^les  Outbreak  167 

were  frequently  met  with,  and  were  distinct  from  the  chronic  adenitic 
swellings  met  with  in  subjects  of  a  scrofulous  tendency,  and  evidently 
unconnected  with  any  special  diathesis. 

It  is  curious  how  often  these  glandular  swellings  have  been  set  down 
as  malarial  fever  or  typhus  fever  with  buboes.  In  this  connection  it 
has  been  held  that  plague  was  an  aggravation  of  either  of  these  diseases, 
and  that  the  one  could  pass  into  the  other.  The  pathological  confusion 
which  gave  rise  to  these  doctrines  has  now  passed  away,  and  it  is  known 
that  each  disease  has  its  own  specific  causal  agent,  and  that  nothing 
will  change  a  malarial  fever  or  a  typhus  fever  into  plague  unless  the 
specific  plague  bacillus  has  been  superadded.  In  India  and  in  South 
Africa  during  the  epidemics  of  plague  prevailing  there  the  plague 
bacillus  has  been  found  in  the  affected  glands  of  the  ambulant  type, 
i.e.  in  those  cases  in  which  the  symptoms  were  so  mild  that  the  patient 
did  not  require  to  take  to  bed.  There  are  other  cases  in  which  it  has 
not  been  found,  and  in  which  it  may  be  taken  that,  though  the  bacillus 
was  in  sufficient  numbers  to  irritate  and  enlarge  the  gland,  it  was  over- 
come by  the  vis  medicatrix  naturae. 

Dr  Tinno\  in  describing  the  small  outbreak  of  plague  at  Naples, 
points  out  that  in  June  and  July  of  1899  and  1900  a  considerable  mor- 
tality occurred  among  the  rats  in  the  port  together  with  a  strange 
illness  among  some  of  the  workmen  of  the  port.  This  illness  was 
characterised  by  the  presence  of  buboes,  which  were  taken  as  venereal 
manifestations  and  treated  as  such,  and  it  was  not  until  October,  1901, 
that  the  real  nature  of  the  disease  was  recognised  in  a  mild  case,  which 
had  also  been  mistaken  at  first  as  venereal. 

Dr  Tinno  recalls  the  fact  that,  in  the  plague  at  Noia  in  1815, 
Dr  Morca  relates  that  in  the  preceding  year  there  were  many  benign 
cases,  whose  nature  escaped  completely  the  attention  of  the  profession 
and  the  laity.  It  was  only  after  the  terrible  explosion  of  the  disease, 
when  the  symptoms  were  rendered  femiliar  to  all,  that  it  was  recognised 
that  in  the  preceding  year  plague  was  in  the  city  and  the  province. 

Cantlie  has  pointed  out  that  previous  to  the  outbreak  of  plague  in 
Hongkong  and  Southern  China  there  was  an  unusual  prevalence  of 
glandular  enlargements  which  attracted  some  discussion  at  the  time  as 
to  their  nature  and  cause.  In  Bombay,  as  has  already  been  mentioned, 
the  epidemic  of  plague  in  its  early  stages  was  called  bubonic  fever 
rather  than  plague,  because  of  the  glandular  enlargements  and  com- 
parative mildness  of  the  symptoms.     In  Calcutta  some  of  the  first  cases 

'  Archives  de  Medecine  crperimentale  et  d' Anatomie  patholoriique,  Jan.  1904. 


168  Fj)idemiolof/f/  of  Plague  [part  ii 

in  1896  were  of  so  mild  a  nature  that  a  controversy  arose  on  the  subject. 

There  can  be  no  doubt,  however,  that  they  were  cases  of  plague,  and 

that  the  mortality  of  rats  in  the  native  mercantile  quarters  of  Calcutta, 

where  the  produce  from  Bombay  was  stored,  was  due  to  plague. 

Not  only  may  the  type  and  virulence  of  plague  vary  in  different 

epidemics,  but  symptoms  may  be  present  in  one  epidemic 
Presence  and  .  %>  ±  j. 

absence  of  which    are    absent   in   another ;    for    example    carbuncles, 

certain  symp-  ^yhid^  appear  to  have  been  an  important  feature  in  many 
toms  in  dif-  i  i  _  _  ...  .        , 

ferent  epi-  of  the  older  epidemics  and  an  indication  of  severity,  have 

emics.  ^^^^  been  conspicuous  for  their  presence  in  the  epidemic 

of  to-day.  When  occasionally  carbuncles  have  been  present  in  the 
existing  pandemic,  they  have,  as  in  the  plague  of  Egypt  in  1884-35, 
rather  indicated  mildness  than  severity.  The  tokens,  also,  that 
were  so  constant  in  fatal  cases  in  the  Great  Plague  of  London  in 
1665  have  not  been  observed  in  recent  epidemics.  Clot  Bey,  alluding 
to  the  presence  in  some  epidemics  and  absence  in  others  of  parti- 
cular symptoms,  points  out  that  in  the  epidemic  of  the  sixth  century, 
to  the  buboes,  carbuncles  and  black  boils  or  pustules  there  were 
added  affections  of  the  throat  and  withering  of  the  limbs ;  that  in 
the  fourteenth  century  lung  affections  were  common,  and  that  in 
the  sixteenth  and  seventeenth  centuries  sweats  were  a  distinguish- 
ing feature.  In  the  Plague  of  London  of  1665  there  were  profuse 
and  extraordinary  sweatings  in  addition  to  the  ordinary  symptoms, 
such  as  shivering,  vomiting,  delirium,  dizziness,  headache,  stupefaction, 
fever,  sleeplessness,  palpitation  of  the  heart,  bleeding  of  the  nose, 
great  heat  aboutv  the  praecordia,  blains,  buboes,  carbuncles,  which 
according  to  Boghurst  did  not  appear  until  July,  spots  and  tokens. 

Hodges,  referring  to  this  particular  symptom,  says  :  "  *  These  sweats 

also  of  the  infected  are  not  only  profuse  but  also  variously 
dinary  and  coloured ;  in  somc  of  a  citron  hue,  m  others  purple,  in 
Bweats^in  the  Some  green  or  black,  and  in  others  like  blood,  which  I 
plague  of  take  to  be  from  the  various  dispositions  of  the  mortified 

venom  to  give  different  tinctures  to  the  humours;  and 
by  this  means  some  experienced  nurses  could  prognosticate  the 
event  of  the  distemper  from  the  colour  of  the  cloaths  or  linen 
tinged  with  the  sweat.  The  sweat  of  some  would  be  so  foetid  and 
intolerable  from  a  kind  of  empyreumatick  disposition,  possibly  of  the 
juices,  that  no  one  could  endure   his  nose  within   the    stench ;   some- 

^  Loimologia,  or  an  Jlifitorical  Account  of  the  Plague  i)i  London  in  166.5.     By  Nath. 
Hodges,  M.D. 


CH.  viii]         Increase  of  Virulence  in  Bombay  169 

times  it  was  sharp  and  in  a  manner  caustick,  and  hence  it  was  easy 
to  judge  from  what  origin  the  pestilence  derived  its  qualities,  viz.  from 
a  sharp  and  burning  ichor  that  would  even  excoriate  the  parts,  and  some- 
times vesicate  them  as  if  scalding  water  had  been  poured  upon  them, 
sometimes  cold  sweats  would  break  out  while  the  heat  raged  inwardly 
and  excited  unquenchable  thirst."  The  variation  of  symptoms  in  indi- 
viduals and  seasons  is  remarked  on  by  Creighton,  who  quotes  Woodall's 
experience  of  London  plague  in  1603,  1625,  and  1636.  A  letter  is 
also  quoted  by  Creighton  on  this  variability:  "'The  practitioners  in 
physic  stand  amazed  to  meet  with  so  many  various  symptoms  which 
they  find  among  their  patients ;  one  week  the  general  distempers  are 
blotches  and  boils,  the  next  week  as  clear  skinned  as  may  be,  but  death 
spares  neither;  one  week  full  of  spots  and  tokens  and  perhaps  the 
succeeding  bill  none  at  all." 

In  the  Moscow  and  Jassy  epidemics  it  is  recorded  that  the  sweat 
had  a  sour  odour  and  so  much  viscosity  as  to  leave  on  the  skin  a  thick 
and  mealy  coating.  In  the  plague  observed  in  Egypt  at  the  end  of  the 
18th  century,  during  the  French  expedition  there,  the  skin  was  observed 
by  the  French  medical  men  to  be  covered  with  a  gummy  or  sticky 
coating,  and  there  were  frequent  haemorrhages.  In  the  pandemic  of 
to-day,  although  occasionally  gangrene,  pustules,  petechiae,  haemorrhages, 
pneumonia,  and  slight  perspirations  are  seen,  yet  none  of  them  are  so 
frequent  or  so  predominant  as  to  give  any  special  character  to  the 
different  epidemics ;  on  the  contrary  their  absence  may  be  considered 
to  be  the  distinguishing  feature,  and  their  presence  as  exceptional.  In 
this  respect  the  present  pandemic  may  be  viewed  as  wanting  in  some  of 
the  more  terrible  features  of  plague ;  whether  this  is  a  sign  of  at- 
tenuation or  degeneration,  or  one  in  which  further  time  and  opportunity 
are  needed  for  more  mature  development,  it  is  impossible  to  say. 

The  epidemic  at  Bombay  in  1896-97  is  an  example  of  plague  be- 
ginning in  a  comparatively  mild  form,  and  in  the  course 
increase  in         f>f  the  outbreak  exhibiting  a  progressive  rise  and  fall  in 
virulence  if  it     yinilence. 
appears  m  the  ... 

same  locality  Thus  at  the  municipal  hospital  the  average  percentage 

^^8°°^^^'^^^       of  case   mortality  which  was  61  "5    was  for   the  different 
months : 

Sept.  Oct.  Nov.  Dec.  Jan.  Feb.         March        April  May 

52-23     52-23     66-67     74-12     69-00     81-64     67-35     56-66     38-46. 
I  History  of  Epidemics  in  Britain,  p.  677.    By  Charles  Creighton,  M.A.,  M.U.,  IB'Jl 


170  EpidemioUmii  of  Plague  [part  it 

The  type  of"  the  disease  in  the  recrudescence  of  the  following  year  was 
however  of  a  more  fatal  character,  and  there  has  been  a  gradual  increase 
in  virulence  with  successive  epidemics. 

In  the  second  epidemic  of  1897-98  the  case  mortality  was  from 
78-55  »/n  at  the  Arthur  Road  Hospital  to  79-26  "/o  at  the  Grant  Road 
Hospital.  The  third  epidemic  of  1898-99  was  still  higher,  in  its  case 
mortality  being  from  78-97  7o  at  Arthur  Road  to  81 -40  70  at  the  Mo- 
dikhana  Hospital.  The  average  mortality  in  5836  cases  treated  at  the 
Modikhana,  Maratha,  and  Arthur  Road  Hospitals  during  1898-99  was 
80-39  "/o-  During  the  fourth  epidemic  of  1899-1900  the  non-serum 
cases  at  Arthur  Road  Hospital  gave  a  mortality  of  79-54,  while  at  the 
Maratha  Hospital  the  mortality  on  2599  cases  was  80-95.  The  normal 
plague  mortality  at  the  public  hospitals  is,  as  observed  by  Dr  Choksy\ 
now  about  80  7o- 

The  virulence  of  plague  became  more  severe  in  Bombay  in  the 
epidemic  of  1900-1901,  and  manifested  itself  in  a  much  larger  pro- 
portion of  cases  with  nudtiple  buboes,  and  in  a  greater  number  of 
septicaemic  cases.  In  previous  epidemics  multiple  buboes  were  only 
to  be  seen  in  13-95  °/o  of  the  cases  treated  in  hospital,  whereas  in  1900- 
1901  they  reached  63  "/o  forming  as  the  epidemic  advanced  the  bulk  of 
the  admissions ;  45  "/o  of  the  cases  were  proved  by  examination  of  the 
blood  and  culture  of  the  bacillus  to  be  already  septicaemic  at  the  time 
of  admission.  Dr  Alfons  Mayr^  in  Bombay  examined  the  blood  by 
culture  of  1014  patients  on  admission  at  the  Maratha  Hospital  during 
1902,  and  found  that  437,  equal  to  43*09  7o>  were  septicaemic  cases. 
None  of  the  septicaemic  cases  recovered.  The  pneumonic  cases  only 
formed  2*44  "/o  against  4-10  Vo  in  previous  epidemics.  In  contrast  to 
this  was  the  very  exceptional  occurrence  of  septicaemic  cases  in  the 
Cape  Town  epidemic,  their  existence  to  the  extent  of  only  5  "/o  in 
Sydney,  and  their  absence  in  the  Brisbane  epidemics.     In  Cape  Town 

the  pneumonic  types  formed   7  Vo  of  the  admissions  and 
Variation  in  .\  -^  f  p  n/^    / 

the  viriUence      lurnished  a  mortality  rate  or  70  "/n. 

of  the  disease  Variation  of  virulence  of  the  disease  is  probably  not 

dependent  on  .  . 

conditions  to       wholly  d(>pendent  on  the  degree  of  virulence  of  the  microbe 

crobe  and  which  changes  with   the  physical   conditions  it  meets  in 

those  attacked     nature,  and   the  opportunity  it    has  of  passing  through 

susceptible  animals,  but  also   on    the    differences   in  the 

1   The  Treatment  of  Plague  with   Profeitsnr  Lvntig's   Serum.     By  N.   H.    Cboksy,   M.D. 
Bombay,  1903. 
'•«  Ibid. 


CH.  viii]    Varying  SusceptibiUfi/  in  Man  and  Animals   171 

predisposition  or  susceptibility  of  those  attacked.  The  facilities  for 
the  plague  microbe  to  become  attenuated  or  exalted  in  the  great 
laboratory  of  Nature  are  not  fewer  than  are  to  be  observed  under 
artificial  conditions  in  the  laboratory.  In  the  latter  a  race  of  microbes 
so  virulent  as  to  cause  the  death  of  a  monkey  or  other  animal 
if  introduced  into  the  body  by  a  mere  puncture  under  the  skin,  can  in 
a  short  time  become  so  weakened  as  to  be  unable  to  cause  death  or  any 
marked  symptom  even  when  given  in  larger  doses.  This  weakened 
race  of  microbes  can  in  their  turn  be  exalted  to  virulence. 

Different  degrees  of  susceptibility  to  plague  are  observed  when 
experimenting  with  the  same  microbe  on  different  animals  at  the  same 
time,  and  even  when  these  animals  are  of  the  same  species ;  one  will 
take  the  disease  almost  at  once,  another  will  only  take  it  after  a  long 
period  has  elapsed,  while  others  will  not  be  affected.  This  varying  pre- 
disposition has  an  important  influence  on  the  type  of  plague  and 
in  the  extent  to  which  it  spreads  in  man.  The  variation  is  seen 
in  different  races,  in  different  communities,  in  different  families, 
and  in  members  of  the  same  family.  It  is  also,  as  stated,  seen 
in  animals  that  are  the  subject  of  experiment,  some  of  which  exhibit 
a  strong  resisting  power  to  the  plague  microbe,  while  others  succumb 
readily  to  its  power  of  attack.  This  resisting  power  or  natural  im- 
munity which  belongs  to  the  majority  unless  the  microbe  has  acquired 
an  exceptional  virulence,  or  has  been  received  in  overwhelming  quantities, 
is  seen  in  every  outbreak,  but  there  are  no  infallible  means  of  recognis- 
ing it  in  the  individual  before  the  ordeal  has  been  passed.  Even  then 
the  same  individual,  who  has  successfully  resisted  the  plague  at  one 
time,  may  not  do  so  on  another  occasion,  so  that  the  resisting  power, 
natural  immunity,  or  non-susceptibility  varies  in  the  same  person  at 
different  times. 

Natural  immunity  has  been  the  subject  of  many  researches  made  to 
Natural  im-  ascertain  in  what  it  consists,  but  these  reseai-ches  have 
munity.  j^^^  yg^  attained  the  object  in  view,  except  in  the  discovery 

of  the  presence  of  protective  substances  in  the  blood  which  are  recognis- 
able mainly  by  their  physiological  effects.  The  production  of  artificial 
immunity  by  injection  of  bacteria  and  their  toxines,  and  the  subsequent 
discovery  of  bactericides  and  antitoxines  thus  formed  in  the  blood,  have 
materially  assisted  these  enquiries.  The  views  generally  held,  founded 
in  large  part  on  Ehrlich's  experimental  work,  are  that  the  specific 
bacteria  or  toxines  thus  injected  merely  furnish  a  stimulus  to  the 
functional  activity  of   the  cells    of  the    body,   causing    them    to    form 


172  Epidemiologii  of  Plague  [part  ii 

iiniimne  bodies  in  larger  quantities  than  usual ;  that  the  property  of 
forming  specific  protective  bodies  is  not,  as  it  seems,  a  newly  acquired 
(juality  caused  by  the  specific  bacteria  or  their  products  which  can 
produce  nothing  in  the  body  which  is  not  already  preformed  in  the 
constitution  of  the  specific  cell  protoplasm,  in  other  words  that 
immunisation  is  only  the  augmentation  of  faculties  already  existing 
in  the  cells,  that  these  inherited  faculties  or  specific  properties  of 
the  cells,  strengthened  or  weakened  by  adaptation  and  selection,  are 
brought  into  every-day  action  by  normal  forces,  and  that  the  .protective 
substances  in  the  blood  are  formed  by  the  assimilation  of  food,  and  will 
according  to  Hueppe  vary  within  certain  limits  with  nutrition,  environ- 
ment and  personal  hygiene. 

According  to  this  view  predisposition,  natural  iuiu^iunity,  and  acquired 
immunity  are  different  manifestations  of  the  same  faculties  of  the 
specific  cells  of  the  body.  This  elaboration  of  protective  substance 
in  the  blood,  which  produces  natural  immunity,  like  all  other  in- 
herited properties  varies  in  different  individuals,  and  is  exalted  or 
weakened  by  natural  forces,  to  which  the  individual  is  subjected.  Foods, 
habits,  environment,  climate,  physical  labour,  and  mental  effort,  when 
suited  to  the  organism,  are  evidently  stimulants  which  increase  the 
natural  elaboration  of  these  protective  substances,  while  when  unsuited 
to  the  organism  and  accompanied  by  misery,  starvation,  depression  and 
anxiety,  they  tend  to  weaken  or  diminish  the  production.  It  is  on  this 
hypothesis  that  the  varying  degrees  of  susceptibility  of  communities  is 
explained,  that  the  influence  of  race,  age,  sex,  comes  into  play,  and  that 
social  and  political  foi'ces,  so  far  as  they  affect  the  food, 
mUsU^seTeat-     welfare  and  condition  of  the  people,  are  important  factors  in 

estravageson  the  spread  of  plague.  Plague  has  nearlv  always  committed 
people  sub-  ^  i  i        "       ■     t        i  i 

jected  to  de-       its  greatest   ravages   on   people    whose    vitality  has   been 

pressing  in-  depressed  by  war,  internecine  conflicts,  scarcity  and 
fluences.  . 

famine. 

The  ravages  committed  by  the  two  great  pandemics  of  plague 
in  543  and  1348,  and  the  great  prevalence  of  plague  during  the 
Mahommedan  supremacy  in  the  East  and  in  Eastern  Europe,  have  been 
attributed  to  social,  economical,  and  political  conditions,  which  at  the 
time  caused  a  decline  in  the  general  prosperity  of  the  people  affected, 
and  rendered  them  more  susceptible  to  the  disease. 

In  the  present  pandemic  variation  in  virulence  is  observable  in 
different  countries.  Thus  in  Hongkong  the  mortality  of  the  epidemic 
ranges  from  89  to  90  "/o  of  those  attacked ;  in  India  from  70  to  85  "/o ; 


CH.  VIIl] 


Case  Mortality  in  Europeans 


173 


Total  plague 

Plague  mortality  of 

ortality  anioug 

Europeans  treated 

Europeans 

in  hospital 

34-6  0/, 

30  to  40  7o 

33-3  o/„ 

24-3  o/„ 

32-4  o/„ 

31-6  7o 

34-5  7o 

440/0 

28-5  o/„ 

in  the  Mauritius  from  68  to  78  ■/„ ;  in  South  America  at  Ascension  it 

was  from  50  to  66  "/o ;  in  Kashmir  it  was  53  "/o ;  in  South  Africa  it  was 

only  48  "/q,  though  for  the  coloured  population  it  was  56  "/o ;  in  Australia 

it  was  3470;  and  in  Chili  it  was  33  "/o- 

Notwithstanding  this   variation   in   virulence   of  the   epidemics   in 

Wbite  people      different  countries  the  case  mortality  among  Europeans  in 

have  a  fairly       different  countries  is   extraordinarily  similar,   and   would 
uniform  mor-        .       .  ...  .... 

taiity  from         indicate   that  predisposition   and  all  it  implies  is  a  very 

evStheTmay     P<^werful  factor  in  combating  plague, 
be  attacked. 


Hongkong 

Bombay 

Cape  Town 

Sydney 

Brisbane 

Oporto 

Glasgow 

It  is  possible  that  this  greater  resistance  of  the  white  is  only  of 
comparatively  modern  development,  and  it  is  a  question  how  long 
it  will  continue  once  the  microbe  adapts  itself  to  European  conditions. 
In  Bombay  there  was  evidently,  even  in  the  case  of  natives,  a  greater 
resistance  to  the  first  epidemic  than  to  subsequent  epidemics. 

The  clinical  features  of  plague  in  China,  in  India,  and  in  South 
Africa,  though  presenting  in  common  glandular  affections  and  nervous 
incoordination,  exhibited  great  differences  in  intensity  as  a  whole. 
The  difference  in  severity  and  in  type  was  conspicuous,  and  it  is  possible 
that  this  difference  in  severity  accounts  for  the  somewhat  conflicting 
accounts  as  regards  mode  of  conveyance,  channels  of  infection,  and  the 
extent  to  which  animals  are  affected  in  the  different  countries.  The 
disease  in  Hongkong  is  more  virulent  among  the  Chinese,  and  in 
Bombay  among  the  Indians,  than  it  is  among  the  coloured  population 
of  South  Africa,  being  about  90  "/o,  80  "/n,  and  60  "/o  respectively. 

Locality  and  environment  seem  to  have  some  influence,  for  if  these 
susceptible  races  are  attacked  elsewhere  the  mortality  is 
often  much  less.  If  one  may  judge  of  the  account  of  the 
plague  in  Iquique  in  Chili,  given  by  Dr  J.  M.  Clarke  in 
1903  after  personal  observation,  the  plague  there  is  even 
more  modified  than  in  South  Africa  or  Australia.  The 
disease  seems  to  have  had  very  much  its  own  way,  little  effort  being 


Susceptible 
races  may 
become  less 
susceptible 
out  of  their 
own  country 


174  Epidemiologif  of  Plaffue  [part  n 

made  to  combat  it ;  500  or  600  cases  out  of  a  population  of 
30,000  would  indicate  that  it  was  a  self-limiting  plague.  Whether 
the  mildness  was  due  to  Iquique  being  in  the  rainless  zone  of  South 
America  and  only  20°  from  the  equator  remains  to  be  seen.  The 
nationalities  at  Iquique  are  very  mixed,  consisting  of  Chilians,  Peru- 
vians, Bolivians,  Indians  and  Chinese,  but  the  disease  was  confined 
mainly  to  the  yellow  and  dark-skinned  races  and  to  the  half-breeds. 

Personal  cleanliness  is  at  a  discount  among  the  lower  orders,  many 
of  whom  never  wash  the  whole  of  their  bodies.  In  the  case  of  the 
women  and  children  a  garment  or  dress  is  put  on  when  new  and 
allowed  to  remain  on  until  it  falls  into  rags ;  in  some  cases  when  a 
new  dress  is  bought  it  is  fitted  over  the  top  of  the  old  one.  Dr  Clarke 
states  that  the  single  men  scarcely  ever  own  a  room  or  portion  of  a 
room  alone.  The  climate  being  good  they  live  in  the  daytime  out  of 
doors;  at  night  a  half-dozen  or  even  more  will  occupy  one  room  in 
which  there  is  no  window,  and  sleep  on  pieces  of  sacking  spread  on  an 
earthen  floor,  and  this  sacking  is  never  swept,  turned  over,  or  brushed. 
Closets  and  urinals  being  unknown  among  the  lowest  orders  the  natural 
functions  are  performed  outside  and  in  proximity  to  the  house.  Still, 
even  under  these  conditions,  the  disease  was  of  a  mild  character,  the 
young  were  most  frequently  attacked,  females  formed  66  "/o  of  the  cases. 
For  the  most  part  the  fatal  cases  occurred  between  the  ages  of  16  and 
22,  and  often  death  did  not  take  place  until  the  lapse  of  20  to  25  days. 
There  was  great  confusion  between  plague  and  venereal  cases,  the 
former  being  put  down  to  the  latter. 

Even  in  India  with  its  usual  mortality  ranging  between  70  and  85  7o> 
Susceptibility     there  are  instances  in  which  the  mortality  was  exceedingly 

may  vary  in  small,  not  at  the  beginning:  but  throughout  the  epidemic, 
the  same  race  o  o  o  i      ^ 

in  different  The  outbreak  among  the  Souttars  of  Kosumba  village 
localities.  jg   .^  ^g^gg   \^   point.     Here,  according  to   Dr  Dyson ^,  the 

Sanitary  Commissioner  of  Gujarat,  the  disease  was  of  a  mild  type 
characterised  by  slight  fever  of  two  or  three  days'  duration,  and  the 
formation  of  buboes,  chiefly  in  the  groin.  "  Fully  three-fourths  of  the 
thirty-one  cases  which  occurred  were  of  this  type,  and  during  one  visit 
to  the  village  I  found  two  boys  about  12  years  of  age  with  buboes  in 
the  groin  whose  fever  had  been  so  slight  as  to  escape  observation,  and 
they  had  not  been  recognised  as  '  plague.' "  Race  was  here  not  a  factor 
in  the  attenuation,  for  in  neighbouring  villages  the  disease  was  virulent. 

^  Account  of  Plague  administration  in  the  Bombay  Presidency  from  September  1896  till 
May  1897,  p.  243.     By  M.  E.  Couchman,  1897. 


CH.  viii]         Dissimilanty  of  Plague  Ejndemic  175 

Some  local  conditions  connected  either  with  environment  or  food  or 
both  appear  to  have  affected  the  constitution  of  the  inhabitants  and 
rendered  them  more  resistant  or  to  have  modified  the  virulence  of  the 
attacking  microbe. 

Variety  of  type  is  seen  in  all  infectious  diseases.     Cholera  at  one 
^    .        -  time  will  become  epidemic,  causing  between  70  and  80  "/o 

type  is  seen  of  a  mortalit}',  while  at  another  time  the  mortality  only 
fectious  reaches  from  18  to  20"/,,.     The  same  is  seen  with  small- 

diseases,  pox.     In  one  epidemic  it  is  of  a  malignant  character  and 

verj'  fatal,  while  at  another  it  is  mild  and  with  a  small  death-rate. 
Scarlet  fever  has  changed  within  the  last  20  years  from  a  compara- 
tively malignant  and  serious  disease  to  one  that  is  so  mild  at  times 
as  to  be  scarcely  recognisable.  Mildness  is  no  more  permanent  than 
severity,  and  with  the  ever-changing  conditions  of  nature  variation 
in  type  becomes  a  general  law.  It  is  impossible  to  say  when  a  mild 
form  of  plague  will  become  virulent,  or  this  in  turn  become  mild.  The 
transformation  is,  nevertheless,  a  real  one  though  the  conditions  which 
bring  it  about  are  unknown.  Another  cause  of  increased  virulence 
may  be  the  association  of  the  plague  microbe  with  other  microbes. 
There  can  be  little  doubt  that  the  early  decomposition  to  which  plague 
bodies  are  liable  in  some  epidemics,  and  the  offensive  smell  that  is 
stated  to  arise  from  the  patients,  are  due,  not  to  the  disease  of  plague 
alone,  but  to  mixed  infection.  Plague  may  begin  in  a  mild  form  in 
a  new  locality,  then  pass  to  a  virulent  variety  which  on  reaching  epidemic 
proportions  gradually  declines,  and  in  the  stage  of  decline  loses  its 
malignity  and  returns  to  the  mild  form  ;  or  it  may  commence  in  a 
severe  form  and  continue  to  be  severe  throughout  the  epidemic  or 
gradually  become  milder ;  or  it  may  begin  in  a  mild  form  and  remain  so 
to  the  end. 


CHAPTER  IX. 

FOSTERING  CONDITIONS   OF   ENDEMICITY   AND   EPIDEMICITY. 

While  the  duration  of  individual  epidemics  varies,  so  also  does  the 
duration  of  the  existence  of  plague  in  a  country  which  it  has  invaded. 
A  city  may  be  visited  by  a  short  and  sharp  epidemic  lasting  only  one 
season  as  in  Cape  Town,  or  it  may  continue  year  after  year  as  in 
Bombay.  It  is  often  difficult  to  determine  when  the  recurrences  of 
Discrimina-  ph^gu©  in  a  locality  merge  into  endemicity,  or  in  other 
tion  between  words  into  the  acclimatisation  and  the  development  of 
recrudescence      , ,         i  •  ,  mi  n  •  i    •   • 

and  the    disease    m  a  new  centre,      ihere  are  tew  epidemics 

endemicity.  ^j^g^j^  ^j-g  qq^  followed  by  one  or  more  recrudescences 
of  smaller  or  larger  dimensions  during  the  subsequent  year,  and 
some  of  these  recrudescences  may  occur  for  several  successive  years. 
Certain  localities  may  even  suffer  from  periodical  and  frequent 
epidemics,  and  yet  the  disease  may  not  be  endemic  though  it  may 
have  all  the  appearances  of  such,  because  the  locality  by  its  situation 
may  be  exposed  to  fresh  importation  and  may  have  scarcely  recovered 
from  the  effects  of  one  epidemic  with  its  recrudescences  before  it  is 
subjected  to  the  onset  of  another.  These  though  often  viewed  as 
endemic  areas  do  not  come  under  the  category  of  those  localities  in 
which  the  disease  manifests  itself  sometimes  sporadically,  sometimes 
epidemically,  for  a  long  series  of  years. 

It  is  possible  that  this  was  the  case  with  Egypt,  which  for  centuries 
was  viewed  as  one  of  the  birth-places  of  plague.  It  is  remarkable, 
however,  that  when  Egypt  was  politically  cut  off  from  Mesopotamia 
and  stood  in  its  relations  to  the  region  of  the  Euphrates  valley  in  an 
isolated  and  independent  position,  it  remained  free  of  plague  for  nearly 
300  years.  It  is,  moreover,  curious  that  when  quarantine  was  intro- 
duced into  the  Ottoman  Empire  plague  soon  died  out  in  Egypt  and  in 
Turkey.     Before  quarantine   the  epidemics  of  Turkey  infected   Egypt 


CH.  ix]  E)i(lemlc  Centres  177 

and  vice  versa  the  epidemics  of  Egypt  infected  Turkey.  Quarantine 
was  introduced  into  the  Turkish  dominions  in  1838,  and  in  Alexandria 
an  International  Sanitary  Council  for  maritime  and  (juarantine  purposes 
was  established  in  1831.  Plague  disappeared  from  both  countries  by 
1845,  assisted  no  doubt  by  the  decay  into  which  the  trade  and  commerce 
of  Bagdad  with  the  West  had  fallen.  A  similar  relationship  exists 
between  Canton  and  Hongkong,  by  which  new  infections  are  introduced 
and  epidemics  maintained.  When  plague  becomes  dangerous  in  Canton, 
large  numbers  leave  for  Hongkong  and  bring  to  the  colony  fresh  and 
virulent  infection,  and  when  plague  increases  in  Hongkong,  people  leave 
for  Cant(jn  and  take  with  them  virulent  plague. 

There  are  certain  localities,  however,  in  which  the  disease  has 
Endemic  prevailed  for  many  years.    Such  are  Kumaon  and  Garhwal 

centres.  j^-j  India,  and  Yunnan  in  China,  Assyr  in  Western  Arabia, 

and  Irak  Arabi  in  the  valley  of  the  Euphrates.  There  are  other 
localities  where  it  reappears  without  trace  of  importation,  such  as  in  the 
Benghazi  district  in  Northern  Africa  and  in  the  highlands  of  Turkish 
Kurdistan.  New  foci  have  also  recently  been  discovered  in  the  Trans- 
baikal  province  in  the  neighbourhood  of  Lake  Baikal,  and  also  in  the 
vicinity  of  the  great  lakes  of  Uganda. 

Perhaps  when  more  is  known  of  these  endemic  centres  it  will  be 
found  that  endemicity  even  in  relation  to  them  is  only  a  relative  term 
and  that  there  are  no  endemic  areas  in  the  sense  of  plague  never  being 
absent  from  them.  At  all  events  this  and  other  kindred  questions 
of  epidemiology  and  etiology  will  only  be  decided  by  lengthened  in- 
vestigation in  some  of  these  so-called  endemic  centres. 

The  old  endemic  areas  in  the  region  of  the  Tigris  and  Euphrates 
valleys  are   still   centres   in   which   plague   is  endemic,  but  since    the 

discovery  of  plaarue  in  the  higfhlands  of  Kurdistan,  it  has 
Kurdistan  •/  i      o  o 

been  suggested  by  Tholozan  that  Bagdad  and  the  sur- 
rounding towns  and  villages  receive  their  plague  from  Kurdistan,  which 
is  the  actual  endemic  centre  of  this  region.  Babylon  and  Bagdad  under 
these  circumstances  from  their  important  commercial  relations  are  likely 
to  have  been  the  distributing  centres  to  Syria,  Egypt  and  Persia,  just  as 
Canton  and  Hongkong  are  to-day  the  distributing  centres  of  the  plague 
from  the  endemic  centre  of  Yunnan.  The  endemic  areas,  as  now  known, 
are  chiefly  distinguished  for  their  high  altitudes,  for  the  poverty  and  tilth 
of  the  inhabitants,  and  for  the  promiscuous  manner  in  which  the  cattle, 
fowls,  and  domestic  animals  are  permitted  to  live  in  close  association 
with  human  beings,  the  former  often  occupying  the  same  room  as 
s.  12 


178  Epidemiology  of  Plarjue  [part  ii 

the  latter.  It  is  found  also  that  the  plague  lingers  longest  in  low- 
lying  countries  in  which  the  habits  of  the  people  are  similar  to  those 
of  the  highlands. 

Apart  from  epidemics  in  India,  there  has  existed  in  the  North-west 
Provinces  since  1823,  probably  longer,  an  endemic  plague  centre  in  the 
Kumaon  and  districts  of  Kumaon  and  Garhwal  situated  on  the  southern 
Garhwai.  slopes  of  the  Himalayas.     These  districts,  the  snow-clad 

peaks  of  which  rise  to  an  elevation  of  23,000  to  26,000  feet,  are  bounded 
on  the  north  by  the  Himalayan  range  and  by  the  Thibetan  frontier,  and 
on  the  south  by  the  plains  of  India.  They  lie  between  latitude  28°  14'  15" 
and  31°  5'  30"  and  east  longitude  76°  6'  30"  and  80°  58'  15"  and  embrace 
an  area  of  over  11,000  square  miles,  in  only  half  of  which  are  found 
localities  adapted  for  cultivation ;  of  this  half,  three-fifths  are  always 
covered  with  snow,  one-fifth  is  cultivated,  and  the  remainder  is  not\ 
The  average  altitude  of  the  mountain  ridges  is  about  7000  feet  above 
the  level  of  the  sea.  The  greater  part  of  the  population  lives  at  from 
3000  to  6000  feet  above  sea  level  and  consists  mainly  of  Hindus.  The 
villages  are  scattered  over  the  mountain  side,  exposed  to  the  pure  air 
of  the  hills  and  supplied  with  water  from  mountain  streams.  Villages 
thus  situated  are  about  the  last  places  which  one  would  expect  to  find 
to  be  the  seat  of  an  infectious  disease  such  as  plague,  yet  it  is  here 
that  the  disease  is  known  to  have  prevailed  in  1823,  1834,  1835,  1846, 
1847,  1849,  1850,  1851,  1852,  1853,  1854,  1859,  1860,  1870,  1876,  1877, 
1884,  1886,  1887,  1888,  1891,  1893,  1894,  1896  and  1897^  The  local 
names  by  which  it  is  known  in  the  Himalaj'as  are  Mahamari,  and  Gola 
or  Phulkiya  Rog.  The  .sjaiiptoms  and  post-mortem  appearances  of 
Mahamari  are  identical  with  those  of  plague  and  are  thus  described 
by  Dr  Pearson :  "  Chilliness,  giddiness,  unusually  severe  headache, 
pain  and  throbbing  of  the  temples,  trembling  of  the  limbs,  inability  to 
Characteris-  remain  in  the  erect  posture,  great  prostration  of  strength, 
tics  of  the  fever  continued,  thirst,    tongue  foul,  chalky    white,    eyes 

O  U  til)  T'6  elk  S 

heavy,  watery  and  injected,  breathing  hurried,  pulse 
small,  frc(iuent  and  unequal,  nausea,  vomiting  and  purging  of  bilious 
matters,  urine  high-coloured,  clammy  perspiration  and  heat  and 
burning  of  praecordia,  occasionally  yellowness  of  the  skin  and  eyes, 
wandering  delirium,  buboes  in  the  groins,  glandular  swellings  in  the 
axilla,  or  neck,  carbuncles,  petechiae,  expectoration  of  blood,  convulsions, 

^  "Endemic  Plague  in  India."    By  Surgeon-General  C.  R.  Francis,  M.B.    Transactions 
of  the  Epidemiological  Society  of  London,  Vol.  iv.  1879-80. 
2  The  Plague  in  India  1896  and  1897.     By  R.  Nathan. 


CH.  ix]  Mahamari  179 

coma  terminating  in  death  on  the  third  or  fourth  day."  The  earlier 
cases  are  often  without  buboes,  being  evidently  of  the  septicaemic  and 
pneumonic  varieties,  and  the  later  with  buboes  but  evidently  of  a 
virulent  type.  In  a  recent  outbreak  of  plague  in  Garhwal  in  which 
the  disease  was  not  imported  from  the  plains,  film  specimens  and 
cultures  made  by  Dr  Chayton  White  were  identified  by  Haffkine  and 
Hankin  as  plague  bacilli.  The  view  that  Mahamari  and  the  Black 
Death  are  different  diseases  from  bubonic  plague  can  no  longer  be 
entertained. 

The  disease  varies  in  its  diffusive  power,  sometimes  being  more  or 
less  sporadic  and  confined  to  a  few  houses  or  to  a  village,  at  other 
times  extending  to  many  villages  or  even  down  to  the  plains  as  occurred 
in  1853-54.  In  the  1853-54  epidemic  there  were  about  8000  deaths. 
It  is  for  the  most  part  very  virulent,  ending  in  death  in  the  third  or 
fourth  da^^  In  Dr  Kenny's  report'  of  1850  it  is  stated  that  "the 
mortality  from  Mahamari  is  very  great,  not  so  much  in  actual  numbers 
as  relatively  to  the  small  amount  of  the  population.  The  recent 
mortality  has  been  estimated  by  the  civil  authorities  to  be  probably 
25  "/u  of  the  total  population.  Recent  enquiries  show  it  to  have  been 
even  greater,  but  the  statistical  details  are  most  defective.  In  certain 
places  the  destruction  has  been  very  great,  of  which  an  example  has  been 
given  of  14  deaths  out  of  16  people  in  one  place.  In  the  village  of 
Sarkoto  in  1846-47,  if  the  reports  of  the  inhabitants  can  be  trusted, 
out  of  a  population  of  65  in  all,  43  died,  two  only  recovered  and  20 
remained  without  infection." 

Probably  during  the  intervals  of  the  virulent  type  there  are  mild 
cases.  When  Mahamari  descended  into  the  plains  in  1853  so  mild 
were  the  few  cases  at  Kasheepore  that  Dr  Stiven  was  of  opinion 
that  the  swellings  in  the  groin  and  arm-pit  were  not  in  the  least 
suggestive  that  the  cases  were  analogous  to  Mahamari.  On  further 
experience  he  formed  an  opposite  opinion  and  he  believed  that  they 
were  cases  of  Mahamari  modified  by  the  diluted  nature  of  the  infection. 
Whenever  the  disease  breaks  out  in  a  village  the  inhabitants  leave 
their  houses  and  encamp  at  some  distance  on  the  hill  side  until  they 
think  the  infection  is  over.  But  as  the  first  cases  are  frequently 
without  buboes  the  village  may  not  be  vacated  until  a  fair  number 
is  attacked  and  glandular  swellings  appear  as  one  of  the  symptoms. 
A  precursory   sign   which   almost   invariably  appears   is   the   death   of 

1  Medical  Report  on  the  Maliamurree  in  Garhwal  in  1849-50,  aud  Appendices,  p.  18. 
By  Dr  G.  Kenny,  Superintending  Surgeon,  Meerut  Division,  Agra,  1851. 

12 2 


180  Epklemiologii  of  Plaffue  [part  ii 

rats    in    a   village  before    plague    breaks   out.     It  is  seldom   that  the 

inhabitants  avail   themselves  of  the   sign.      Dr  Hutcheson'   mentions 

the   case  of  a  village  where   the  inhabitants  vacated  their  houses  on 

account  of  a  great  mortality  among  rats  and  mice,  and  thus  an  outbreak 

of  Mahamari  was  in  all  probability  averted. 

That  plague   should   prevail  endemically  in   high   altitudes  and  in 

sparsely  populated   districts  with  a  salubrious  climate,  and  with   the 

natural  surroundings  of  the   villages  exceptionally  healthy,  would  be 

per))lexine:  were  it  not  that  the  effects  of  the.se  hygienic 
Poverty  of the      ^      \.   .      °  ,        ,       i    p  i   i        ,         •         i      i      i     j 

inhabitants,        conditions  are  completely  defeated  by  the  singularly  bad 

exceptionauy      conditions   under  which   the   people  live   in   their  houses 

insanitary  .  . 

houses  and         and  which  are  highly  favourable  to  the  maintenance  and 

tion^of  ^^°'^^^'     dissemination  of  disease.     It  has  already  been  stated  that 
animals  the    people    in   endemic    areas    are    usually  poor   and  ill- 

nourished.  To  these  may  now  be  added  exceptionally 
insanitary  surroundings.  For  Garhwal  and  Kumaon  there  is  the 
testimony  of  Drs  Renny,  Pearson,  Francis  and  Planch  who  have  at 
different  times  investigated  some  of  the  outbreaks.  Each  of  them 
agrees  in  emphasising  the  extraordinary  filthiness  of  the  dwellings  and 
the  uncleanliness  of  the  inhabitants  owing  to  the  houses  accommo- 
dating men  and  animals  together. 

In  1850  Dr  Renny-  reported  that  "the  filth  is  everywhere  in  their 
villages,  their  houses  and  their  persons.  It  destroys  the  otherwise  pure 
quality  of  the  air  and  maintains  ever  round  the  inhabitants  that 
contaminated  atmosphere  so  favourable  to  the  condensation  of  infectious 
emanations.  Their  dwellings  are  generally  low  and  ill-ventilated  except 
through  their  bad  construction ;  and  the  advantage  to  the  natives  in 
other  parts  of  India  of  living  in  the  open  air  is  lost  to  the  villagers  of 
Garhwal  from  the  necessity  of  their  crowding  together  for  mutual 
warmth  and  shelter  against  the  inclemency  of  the  weather.  The  food 
of  the  majority  is  bad  and  insufficient."  Dr  C.  R.  Francis-',  who  investi- 
gated the  disease  in  1858  along  with  Dr  Pearson,  in  discussing  the  cause 
of  Mahamari  and  how  it  is  propagated,  says,  "  I  am  afraid  that  we 
have  no  better  answer  to  the  first  question  than  we  had  thirty  years 
ago.     We  now  know    indeed,  as  we  presumed  then,   that  insanitation 

'  "  Maliamari,  or  the  Plague  in  British  Garhwal  and  Kumaon. "  By  J.  Hutcheson,  M.D. 
Transactions  of  the  First  Indian  Medical  Goni/ress,  1894. 

-  Medical  Report  on  the  Mahamurree  in  Garhwal  in  1849-5(1,  and  Appendices,  p.  11. 
By  Dr  C.  Eenny,  Superintending  Surgeon,  Meerut  Division,  Agra,  1851. 

3  "  Endemic  Plague  in  India."  By  Surgeon-General  C.  R.  Francis.  Transactions  of  the 
Epidemiological  Society,  Vol.  iv.  1879-80. 


CH.  ix]  Co7iditions  in  Kumaon  181 

fosters  the  disease  and  doubtless  invites  outbreaks ;  for  a  relaxation  of 

hygienic    regulations   (partly  as  a   result   of  the   mutiny  of  1857   and 

partly,  it  must  be  added,  in  consequence  of  the  chief  civil  authorities  in 

Kumaon   not    believing  in  and   therefore  not  rigidly  enforcing  them) 

always  has  been  followed  by  the  reappearance  of  the  disease  in  as  violent 

a  form  as  ever.     From  1854  to  1857,  during  which  period  owing  to  the 

energy  of  Mr  (now  Sir  John)  Strachey  in  Garhwal  sanitary  progress  was 

there    most    vigorous    and    effective,    the    plague    was    comparatively 

quiescent;    but  in   1859  and  again  in  1860  it  visited  the   Northern 

Pergunnahs  in  Kumaon  with  great  severity ;  and  in  these  years  1000 

persons  died  from  the  disease.     Again  in  1876-77  there  occurred  291 

cases  of  which   277  were  fatal — a  death-rate  of  about  95  per  cent. ! 

(The    official    returns    show    that    3600    deaths   from   Mahamari   have 

occurred  since  its  first  appearance  in  1823.)     Until  hygienic  measures 

were  adopted,  the  general  uncleanliness  of  the  people  in  their  persons  and 

entouracje  was  incredible.     A  small  stone  dwelling  (built  upon  a  surface 

^  „       .  ,         13  feet  square)  consisting  of  two  rooms  each  about  5  feet 
Dr  Francis  . 

description  of  high,  one  above  another — the  upper  chimneyless  and 
practically  windowless — tenanted  by  the  entire  family 
of  often  more  than  half-a-dozen  in  number  and  by  huge  baskets 
containing  the  family  grain ;  the  lower  compartment  (a  wooden 
floor,  full  of  cracks  serving  as  media  for  the  effluvium  from  below, 
dividing  the  two)  being  occupied  by  the  family  herds  consisting 
of  cows,  goats  and  pigs ;  a  row  of  such  dwellings  (sometimes  they 
are  single  or  double)  spread  over  an  irregular  surface  similarly 
tenanted  and  flanked  at  either  extremity  by  the  ancestral  heap  of 
manure  from  which  streamlets  of  liquid  filth  were  flowing  in  different 
directions;  the  cottages  covered  with  cucurbitaceous  creepers,  as 
cucumbers,  pumpkins,  melons  and  the  like ;  a  small  forest  of  hemp, 
some  8  or  10  feet  high,  luxuriating  in  the  immediate  neighbourhood  of 
the  village ;  a  growth  of  underwood  including  nettles,  &c.,  between  the 
two,  and  more  or  less  surrounding  the  latter ;  and  unwashed  Pater- 
familias, seated  in  front  of  his  fig-tree,  having  submitted  his  head  to  be 
divested  of  the  light  infantry  skirmishing  in  his  unkempt  hair ! 
Conceive  such  a  village  situated  towards  the  base  of  a  mountainous 
slope,  well  within  the  range  of  whatever  noxious  influences  may 
emanate  from  the  valley  below ;  located  where  there  would  be  the 
veriest  minimum  of  ventilation ;  and  we  cannot  be  surprised  then  when 
sickness  does  come,  it  should  run  rampant." 

In  1876  Dr  Planch'  says  of  the  infected  village  of  Kumaon:  "The 

'  Report  of  the  Siniitary   Commissioner  for  the  North-West  Provinces  for  1876. 


182  Epidemiolof/t/  of  Plague  [part  n 

houses    were    double-storied,    one    room    below    and    one    above,   close, 

T^  T,,      ^,.  ill-ventilated    tenements.     The    lower  room   was    used   as 

Dr  Plancn  s 

description  of  a  cow-house,  the  upper  room  for  family  occupation, 
the  houses.  j^^  ^j^^  lower  room,  about  5  feet  hitrh,  it  had  been 
customary  to  lodge  from  4  to  8  head  of  cattle  or  goats  at  night,  and 
indeed  in  some  instances  as  many  as  the  room  had  standing  room 
for;  the  only  opening  being  the  small  doorway  of  entrance,  tight 
closed  and  barred  at  night.  These  rooms  were  seen  to  be  littered  for 
about  a  foot  in  depth  with  decaying  straw  and  much  manure,  moistened 
by  the  fluid  excrement  of  cattle,  and  the  entrance  way  on  each  side  and 
the  stone  platform  facing  the  lower  story  were  piled  with  heaps  of 
manure  which  had  been  drawn  out  of  the  lower  room  as  necessity 
required  and  there  left  for  eventual  removal  to  the  land  in  the  ploughing 
season.  The  upper  room  was  noticed  to  be  roughly  divided  by  wooden 
slabs  into  a  front  and  back  portion ;  the  former  used  as  the  family 
sleeping  place,  the  latter  as  a  granary.  The  doorway,  and  in  some 
instances  a  round  hole  in  the  front,  and  a  small  round  hole  for  the  exit 
of  smoke  through  the  roof  of  the  house,  all  commonly  closed  at  night, 
were  the  only  openings.  The  floor  was  made  of  thin  wood,  with  pretty 
numerous  cracks  so  that  the  warmth  generated  by  the  cattle  below  could 
reach  to  the  sleeping  people  above,  aftenvards  locally  described  as 
beneficial." 

Dr  Francis  in  his  description  adds  pigs  to  the  number  of  domestic 
animals  occupying  the  lower  floor  of  the  house. 

The  similarity  of  the  description  of  one  endemic  centre  to  another  is 
very  striking,  whether  it  is  in  India,  China,  Persia,  Mesopotamia,  Ai'abia, 
or  North  Africa. 

Yunnan,  the  endemic  centre  in  China,  has  alread}-  been  described. 
Conditions  in  Like  Kumat)n  and  Garhwal  it  is  some  5000  to  6000  feet 
Yunnan.  above  the  level  of  the  sea,  the  inhabitants  live  crowded 

in  their  dvvelling-houses,  and  are  much  associated  in  their  domestic 
life  with  their  cattle,  pigs,  and  poultry.  The  same  phenomenon  of 
mortality  among  rats  precedes  an  outbreak  of  plague  as  in  Kumaon 
and  Garhwal.  The  rats  leave  their  holes,  lose  their  timidity,  stagger 
about  and  then  fall  down  dead.  Large  numbers  die  under  the  floor, 
where,  putrefying,  they  give  rise  to  most  offensive  smells.  The  in- 
habitants, knowing  the  signs,  immediately  begin  to  take  precautions  by 
burning  charcoal  in  their  rooms,  and  in  certain  places  they  abstain 
from  eating  pork.  In  connection  with  the  abstention  from  eating  pork 
at  these  times  attention  may  here  be  drawn  to  the  custom  of  eating  raw 
meat.    Such  a  custom  may  assist  in  maintaining  the  endemicity  of  plague. 


CH.  ix]  Conditions  in  Assyr  183 

Marco  Polo  says :  "  'Let  me  tell  you  also  that  the  peoj^le  of  that  country 
(Yunnan)  eat  their  meat  raw,  Avhether  it  be  of  mutton,  beef,  buffalo, 
poultry  or  any  other  kind.  Thus  the  poor  people  will  go  to  the 
shambles,  and  take  the  raw  liver  as  it  comes  from  the  carcase  and 
so  eat  it;  and  other  meat  in  like  manner  raw,  just  as  we  eat  meat  that 
is  dressed."  Besides  rats,  other  animals  such  as  buffaloes,  oxen,  sheep, 
and  deer,  and  sometimes  court-yard  fowls  have  been  observed  to  take 
the  disease.  The  disposal  of  the  dead,  both  of  man  and  animals  who 
die  of  this  disease,  is  defective. 

The  endemic  centre  in  the  plateau  of  Assyr,  Western  Arabia,  is 
Conditions  '^Iso  situated  upon  a  range  of  high  mountains,  the 
in  Assyr.  affected    villages   being   some    5000  to    6000    feet   above 

the  level  of  the  sea.  Dr  Dickson,  quoting  the  report  of  Dr  Nouri, 
who  proceeded  on  a  mission  of  enquiry  in  1879,  referring  to  Namasse, 
the  seat  of  government  of  this  district,  says :  "  The  climate  of  this 
region  is  cold  and  damp,  but  the  soil  is  fertile  and  well  watered 
with  pure  limpid  springs.  It  has  no  commercial  transactions  of  any 
consequence  with  other  places,  and  the  inhabitants  merely  cultivate 
what  is  needed  for  their  own  immediate  wants.  The  houses  are 
built  of  stone  and  adjoin  one  another.  They  consist  of  two  stories  and 
contain  one  or  two  rooms  with  or  without  one  or  two  apertures  to  let 
in  the  light.  The  ground-floor  is  used  as  a  stable,  and  as  the  winter 
is  very  cold,  the  inhabitants  live  in  it  together  with  their  animals  in 
a  disgusting  state  of  filth." 

In  the  six  villages  of  the  district  Dr  Nouri  found  that,  in  1874,  out 
of  a  population  of  8000  persons  184  had  been  attacked,  155  had  died, 
and  only  29  had  recovered.  All  these  patients  were  said  to  have 
suffered  from  general  "  malaise  "  and  fever,  or  from  shivering  followed 
by  fever,  more  or  less  from  headache,  in  some  cases  from  great  thirst 
and  want  of  appetite,  diarrhoea,  vomiting,  pain  in  the  groins,  and  in 
other  parts  of  the  body,  with  or  without  buboes,  with  (jr  without  red 
or  black  specks,  broken  dreams,  delirium,  and  insensibility  lasting  for 
several  days.     There  is  no  mention  of  a  rat  mortality. 

It  is  noticeable  that  the  inhabitants  of  the  so-called  endemic  centres 
live  usually  on  the  borderland  of  privation,  any  severe  drought  or 
inundation  placing  them  at  once  in  a  state  of  misery.  In  the  Benghazi 
outbreaks  of  1858  and  1874  those  first  attacked  were  nomadic  tribes 
of  Bedouin  Arabs  living  in  encampments  with  their  cows,  sheep,  and 
goats,  but  owing  to  preceding  droughts  and  failure  of  crops  brought 
to  the  verge  of  famine,  and   later  by  the   inclemency  of  the  weather 

1   The  Book  of  Marco  Polo.     Book  ii.  p.  oi.     By  Colonel  Henr.v  Yule,  C.B.,  1875. 


184  Epidemiolo(f]i  of  Plague  [part  ii 

reduced  to  a  state  of  great  miser}'.  In  the  Assyr  outbreak  of  1874  the 
localities  had  previously  been  visited  by  famine.  In  A[eso})()tamia  in 
18()7  it  was  after  an  excessive  flood  of  the  Euphrates  and  inundation  of 
the  marshes  that  plague  reappeared.  Poverty  and  lack  of  nourishing 
food  seem  to  play  an  important  role  in  the  susceptibility  of  a  community 
to  plague,  and  the  conditions  which  favour  the  prevalence  of  relapsing 
fever  and  typhus  fever  also  favour  the  endemicity  of  plague. 

The  fostering  conditions  of  plague  once  the  disease  has  been  intro- 
Fosterinff  con-  fl^i<^<^d  into  a  locality  are  similar  to  those  already  described 
ditions  of  as  being  found  in   the  endemic  centres.     The  conditions 

lence  similar      "i^'J  iiot  everywhere  present  precisely  the  same  aspects, 

in  exotic  custom  and  race  modifyinff  them,  but  they  are  nevertheless 

localities  to  .  .  <■      o  j 

those  in  en-  associated  with  poverty,  overcrowding,  bad  ventilation  of 
emiccen  res.  i,,,|i>^^.s,  and  filth,  and  the  concomitants  of  these.  Though 
perhaps  not  exactly  the  agents  which  disseminate  plague  they  are  the 
auxiliaries  which  facilitate  its  progress.  To-day  they  are  found  in  their 
greatest  intensity  in  Eastern  countries  which  are  in  the  same  condition 
of  sanitation  as  Europe  was  in  the  16th  and  17th  centuries. 

Thus  London  with  its  great  plague  epidemics  of  the  years  1603, 
London  in  the  1625,  1636,  and  1665,  with  their  respective  mortalities  of 
17th  century.  36,000.  35,000, 10,000,  and  68,000,  was  then  ill-constructed, 
with  narrow  and  crooked  streets,  many  of  them  being  unpaved.  The 
houses  were  built  of  wood  and  lofty ;  they  were  dark,  irregular  and  ill- 
contrived,  with  each  story  hanging  over  the  one  below,  so  as  almost  to 
meet  at  top,  and  thereby  preclude  as  much  as  possible  all  access  to 
a  purer  air ;  they  were,  besides,  furnished  with  enormous  signs  which  by 
hanging  in  the  middle  of  the  street  contributed  not  a  little  to  prevent 
ventilation  below.  The  sewers  at  the  same  time  were  in  a  very 
neglected  state  and  the  drains  all  ran  above  ground.  The  metropolis, 
which  now  enjoys  such  a  plentiful  supply  of  water  laid  on  into  every 
house,  had  till  many  years  subsequent  to  the  bringing  in  of  the  New 
River  in  1613  been  but  scantily  furnished  with  this  first  of  luxuries. 
The  condition  of  the  town  is  stated  to  have  been  offensively  dirty\ 

There  were  plague  epidemics  in  Paris  in  1619,  1631,  1638,  1662,  and 

Paris  in  the        ^^^^  '  ^^^ut  the  latter  period  Paris  was  paved,  the  streets 

17th  century,      were  widened  and  the  city  began  to  be  kept   cleaner-. 

igthcentur*^^     These  fostering  conditions  are  far  from  being  absent  even 

now   from    the    gi-eat  centres  of  population  in  the  "West. 

1  Maitland's  Hixtorij  of  London. 

-  Observations  on  the  increase   and  decrease  of  different   Diseases  and  particularly  of 
the  PUit/ue.     By  Win.   Heberden,  Jiin.,  M.D. ,  F.R.S. 


CH.  ix]  Conditions  in  Hongkong  185 

When  Oporto  was  attacked  with  plague  in  1899  it  prevailed  in  those 

portions  of  the  town  which  were  densely  populated,  overcrowded,  and 

with  inadequate  means  for  the  disposal  of  excrement  and  refuse.     "^In 

the  low  class  quarter  of  the  town  the  houses  are  irregularly  built  and 

closely  packed  together  so  as  to  obstruct  the  free  circulation  of  fresh  air 

and  prevent  the  entrance  of  sunlight  into  the  dwellings.     Some  of  the 

houses  are  built  back  to  back,  the  ground-floors  being  damp      Rotten 

garbage  and  other  offensive  matter  are  thrown  out  upon  the  street  and 

are  trodden  into  the  soil  and  add  to  the  unpleasant  odours  of  the  streets. 

Some  houses  are  sub-let  in  tenements,  a  family  occupying  each  room  ; 

often  the  ground-floor  is  used  for  the  stabling  of  animals,  such  as  pigs 

and  goats." 

However  bad  this  may  be  from  an  European  point  of  view  it  is  not 

to  be  compared  with  the  narrow  and  crooked  streets   of 
Canton  in  the       -,  in  -i      • 

i9tii  and  2otii     Canton,  the  lU-ventilation  and  darkness  oi  the  houses  and 

centuries.  j-j-^^  ^Ij-j-j  ^f  ^^^^  streets  ;    nor  with  the    overcrowding   in 

the^mh^and       Hongkong.      The    conditions  in  Hongkong  which  favour 
2otii  cen-  the    prevalence    of    plague,  apart    from    its  proximity  to 

an  infected  part  of  China,  consist  in  its  being  a  great 
emporium  with  immense  warehouses  filled  with  stores  and  infested 
with  rats  susceptible  to  the  disease,  and  its  containing  a  very  high 
proportion  of  poor  people  essentially  of  the  labouring  and  migratory 
class,  and  who  like  all  people  of  this  class  in  Eastern  towns  live 
under  very  insanitary  conditions.  Hongkong  is  peculiar  in  possessing 
a  greater  proportion  of  these  insanitary  classes  and  in  housing  them  on 
a  smaller  space  than  even  Bombay.  Narrow  streets  and  high  houses 
abound  in  which  light  and  air  are  obstructed.  So  closely  packed  are  the 
buildings  in  the  older  portions  of  the  town  and  so  overcrowded  are  the 
houses  that  in  one  district  the  density  of  the  population  reaches 
840  persons  per  acre,  which  is  more  than  three  times  the  most  crowded 
area  of  Calcutta.  Apart,  however,  from  too  many  houses  erected  on  too 
small  a  space,  the  evils  attendant  on  the  overcrowding  of  a  dirty  class 
of  people  are  accentuated  by  the  kind  of  buildings  erected.  Narrow 
streets  and  high  houses  are  not  peculiar  to  Hongkong.  They  are  the 
means  by  which  many  towns  manage  to  house  a  large  population.  But 
in  Hongkong  in  the  Chinese  quarters  defects  in  the  construction  of  the 
houses  intensify  the  obstruction  of  light  produced  by  crowding  together 
of  buildings,  while  subdivision  of  the  rooms  serves  to  increase  the  over- 
crowding. The  rooms  are  long  and  narrow  with  a  window  at  each  end, 
the  front  window  looking  into  a  wide  and  covered  verandah  and  the 
'  "Reports  and  Papers  on  Bubonic  Plague."    By  Dr  11.  Low,  Local  Govt.  Board,  1902. 


18(j  Upldeviiolof/!/  of  Plague  [part  n 

back  window  into  a  small  open  space  at  the  back  which  forms  a  sort  of 
well  between  two  houses.  Sometimes  these  small  spaces  do  not  exist,  so 
that  the  buildings  are  back  to  back.  The  lower  floors  of  many  of  the 
houses  are  remarkable  for  their  darkness  as  well  as  being  frequently 
damp.  Many  of  the  lower  floors  of  the  woret  kind  have  been  changed 
into  store-rooms  to  contain  the  goods  and  merchandise  for  which  Hong- 
kong is  an  entrepot.  These  store-rooms  as  a  rule  are  infested  with  rats, 
which  at  times  find  their  way  up  to  the  rooms  on  the  higher  floors.  The 
basements  are  generally  rat-ridden,  both  floors  and  walls,  and  from  the 
walls  being  often  hollow  it  is  easy  for  rats  to  reach  the  upper  floors. 

The  admission  of  light  into  the  dwelling-rooms  of  Chinese  tenement 
houses  is  still  further  obstructed  by  the  subdivisions  into  several  cabins 
or  compartments,  sometimes  numbering  up  to  six,  which  every  room  is 
subjected  to.  Each  cabin  is  let  out  to  a  separate  tenant  and  not  infre- 
quently accommodates  a  separate  family.  The  compartments  or  cubicles 
are  windowless  rooms  and  are  often  so  dark  that  it  is  impossible  for  any- 
one coming  directly  from  the  light  outside  and  drawing  the  curtain  or 
opening  the  door  of  the  cubicle  to  see  from  the  passage  if  the  cabin  is 
occupied.  Fresh  air  and  sunlight  never  get  into  the  cubicles  except 
perhaps  the  compartment  at  each  end  of  the  room  opposite  the  window. 
The  cubicle  system  as  described  leads  to  overcrowding  in  its  worst  form 
and  under  the  worst  conditions,  for  wherever  more  than  two  cubicles  are 
in  a  room  the  compartments  become  so  dark  as  to  render  it  impossible 
to  be  kept  clean. 

Many  of  the  conditions  which  exist  in  Hongkong  are  also  to  be 
Bombay  in  found  in  Bombay,  but  on  the  whole  the  latter  city  contains 
^®^^-  i)roportionately  fewer  houses  with  windowless  rooms  and 

with  so  much  overcrowding.  There  are,  however,  many  buildings  as 
bad,  and  many  worse  than  in  Hongkong,  but  they  ma\'  in  relation  to 
the  size  of  the  city  be  considered  as  few  in  proportion. 

Bombay,  like  Hongkong,  is  a  port  with  large  warehouses  and  stores, 
and  it  was  in  that  quarter  where  grain  and  rice  are  stored  in  godowns 
and  which  are  infested  with  rats  that  plague  showed  itself  first  in 
epidemic  form.  The  Hindu  low  castes  were  the  greatest  sufferers  from 
the  plague  in  Bombay.  They  are  so  poor  that  they  may  often  be  seen 
searching  among  refuse  for  food ;  their  dwellings  are  situated  in  the 
most  crowded  localities  and  several  families  not  infrequently  live  in  one 
room.  They  usually  sleep  on  the  floor  on  a  thin  sheet,  and  the  ground 
on  which  they  sleep  is  damp  and  mouldy  and  nearly  as  damp  as  the 
street  outside.  In  one  district  of  Bombay  it  is  stated  by  the  Health 
Officer,  Dr  Weir,  that  75  "/„  of  the  buildings  were  more  or  less  unfit  for 


CH.  ix]  Conditions  in  Bombay  187 

human  habitation  by  reason  of  imperfect  ventilation,  darkness,  and 
dampness.  Most  of  the  buildings  consist  of  double  rooms  separated  by 
a  narrow  and  dark  passage  which  ends  in  a  small  open  space  in  which  is 
located  the  privy  on  one  side  and  the  water-tap  on  the  other.  All  the 
clothes  of  the  house  are  washed  in  this  yard  and  the  dripping  of  the 
water  and  the  washing  of  the  clothes  render  the  outside  walls  damp. 
The  rooms  on  each  side  of  the  passage  may  be  further  subdivided,  so 
that  the  centre  rooms  are  in  darkness,  while  the  front  and  back  receive 
but  little  light. 

The  chawls  of  Bombay  enjoy  an  unenviable  reputation  for  being 
The  chawls  huge  warrens  in  which  human  beings  are  packed  under 
of  Bombay.  conditions  which,  though  not  resembling  the  unhealthy 
dwellings  of  the  inhabitants  of  Kumaon  and  Garhwal,  are  in  no  respect 
better  as  regards  light  and  air  and  overcrowding.  They  frequently  consist 
of  high  buildings  of  five  or  six  stories,  sometimes  more  than  100  feet  in 
depth,  and  not  more  than  three  or  four  feet  from  adjoining  buildings  of 
a  similar  type.  The  entrance  door  leads  to  a  long  passage  or  corridor 
which  runs  from  end  to  end  of  the  building.  On  each  side  of  this 
passage  are  rooms  with  windows  occupied  by  one  or  more  families. 
A  staircase  leads  to  the  higher  stories,  which  are  also  arranged  on  the 
same  plan  of  a  long  passage  and  rooms  on  either  side.  The  passages 
receiving  light  from  the  door  and  windows  at  the  end  are  dark  and 
badly  ventilated,  and  the  rooms  abutting  on  these  passages  are  also 
dark  and  badly  ventilated,  owing  to  the  narrowness  of  the  intervening 
gully  between  the  buildings  adjoining.  In  some  inspections  in  which 
the  writer  joined,  having  for  their  object  the  discovery  of  plague  cases, 
lamps  had  to  be  used  to  light  the  way  in  these  houses,  although  it  was 
day  outside,  and  notwithstanding  the  light  on  one  occasion  he  stumbled 
over  a  sick  person  crouched  in  the  darkness.  Each  room  has  one  or 
more  occupants,  and  sometimes  the  inmates  in  the  building  amount  to 
some  hundreds. 

Some  of  these  buildings  are  described  by  the  Health  Officer ^ 
"  In  the  crowded  buildings  in  Mandvi,  in  which  the  disease  first 
appeared,  we  had  over  100  people  in  many  buildings,  and  as  many  as 
000  people  in  one  building,  one  family  living  their  life  in  one  room, 
opening  on  to  a  common  passage  in  which  the  grain  was  ground,  and 
The  crowded  '"^^  ^^"®  ^'^'^  ^^  which  was  the  water-pipe  under  which  the 
buildings  in  clothes  were  washed,  splashing  the  walls  and  the  floor 
around.     We  take  for  explanation  one  building  in  Olive 

'  "  Report  on  the  plague  of   1H90-!J7  in  Bombay."     By  Brigade-Surgeon  Lieut. -Col. 
T.  S.  Weir,  Municipal  Health  Officer,  p.  735. 


188  Epidemiolo<i]i  of  Plague  [part  ii 

Road.  There  are  116  rooms,  and  sa}'  there  are  four  persons  to  each 
room ;  it  gives  nearly  500  people  to  the  house,  and  underneath  this 
mass  of  people  densely  pressed  in  one  building,  with  the  foulness  that 
must  come  from  human  beings,  are  three  godowns  and  shops,  and  yet 
this  is  not  by  any  means  the  most  crowded  and  densely  poj)ulated 
dwelling  in  the  city.  No-one  can  look  at  the  size  of  the  buildings, 
and  the  number  of  rooms  in  each  building  in  this  locality,  as  shown  in 
this  statement,  without  having  a  feeling  of  astonishment  that  the 
mortality  has  been  so  low.  They  are  most  thrifty  people,  the  Jains 
and  other  classes  who  come  hei'e  for  business  from  Gujarat  or  Kathiciwar 
and  live  in  these  buildings ;  they  suffer  as  much  from  thrift  as  other 
classes  from  want  of  thrift ;  they  seldom  eat  fruit,  and  they  use  very 
little  vegetables,  unlike  most  Hindus.  They  are  so  thrifty  that  they 
collect  rags  and  rubbish  in  the  passages  of  the  dwellings,  and  so  careful 
of  animal  life  that  they  fear  to  sweep  near  the  rags  they  have  with 
much  pains  bound  in  bundles.  I  have  never  seen  any 
their  indiflfer-  people  SO  indifferent  to  the  sight  of  the  dying  and  the 
dead.  This  is  what  the  Committee  appointed  by  Govern- 
ment saw  one  evening  during  the  inspection  of  a  building.  In  one 
A  scene  in  room  of  a  large  building  with  double  rooms  on  each  floor 

a  building.  -^y.^g  .^  patient  ill  from  bubonic  plague.  In  the  next  room 
was  a  man  singing.  In  the  room  after  that  there  was  a  dead  body. 
And  in  a  room  almost  after  this  a  group  of  women  were  laughing  at  us. 
It  was  often  pathetic  to  see  the  anxiety  of  some  people  to  save  an  insect 
from  disinfecting  fluid." 

The  number  of  cases  in  buildings  in  Mandvi  Bunder  is  seen  in  the 
annexed  return,  and  the  incidence  of  the  disease  by  dwellings  can  be 
studied  from  it.     "  It  shows 

(a)    the  fatality  by  dwellings, 

(6)   the  effect  of  the  measures  taken  in  the  beginning. 

"  The  mortality  has  been  so  small  in  proportion  to  the  numbers  and 

Mortality  ^^  pressure  of  the  population   and  the  density  of  the 

from  bubonic      houses  that  it   has  been   suggested  by    some  authorities 

owing  to  t\\dX  there   may  be   another   severe   epidemic.     All  who 

measures  have  seen  the  charts  of  mortality  have  ascribed  the  re- 

adopted. 

pressions  in  the  mortality  to  the  influence  of  the  sanitary 

measures  adopted.      There  can  be  no  doubt  that  the  measures  adopted 

have  reduced  and  lightened  the  mortality.     There  is  no  reason  except 

the  influence  of  the  measures  carried  out  why  in  this  city,  more  densely 


CH. IX] 


Cases  in  Single  Buiklings 


189 


crowded   than  any  city  in  the   British  Empire,  the  mortality  has  not 
been  much  greater. 

"  Statement  showing  the  number  of  cases  of  Bubonic  Plague  and 

THE  date  of  attack  AND  DEATH  IN  BUILDINGS  ON  MaNDVI  BuNDER. 


Street 

House 

No. 

Key 

Roman  figures  indicate  date  of  attack  and 

italics  indicate  date  of  death 

1 

Broach  Street 

58  a 

25.%— 31.8;  11.9— i6.9;  12.9;  18.9;  22.9;  28.9— 
i.20;  8.10     i^.iO;  23.12     50.i^;  31.3;  25.4 

28.4 

2 

Argyle  Road     

172-176 

16.9— i<S.9;  20.9— ^i.9;  22.<d—26.9 

3 

CuUian  Street 

33 

n. 9— 20.9;  18.\)— 24.9;  18.9;  21.9—25.9 

4 

Bhandup  Street 

9-13 

18.9—24.9;  19.9;  20.9—25.9;  22.9;  28.9;  4.4 

5 

Akbar  Street    ... 

Shed 

18.9— .25.9 

6 

Musjid  Siding  Road   ... 

50-54 

20.9  — ;^5.9;  25.9  —  27.9;  16.10;  16.10;  17.10; 
21.10;  21.10;  22.10— 26.10;  SO.IO— 2.11;  2.11 

7 

Do. 

22 

20.9—24.9;  22.9—24.9;  2S.9— 28.9;  25.9—30.9; 
25.9—27.9;  26.9—30.9;  21.9—29.9;  27.9— 
4.10;  28.9;  30.9— 5. JO;  ^.9—3.10 

Do. 

22 

1.10—3.10;  1.10—3.10;  2.10;  2.10—3.10;  2.10; 
2.10 

8 

Argyle  Road    ... 

22 

20.9—^5.9;  20.9—27.9;  21.9—29.9;  28.9—30.9; 
30.9—30.10 

9 

Musjid  Station  Road... 

25 

20.9—23.9;  21.9-30.9;  2.10;  25.10—26.10 

10 

Argyle  Road     

47 

20.9—24.9 

11 

Musjid  Station  Road... 

24 

21.9;  28.9;  28.9— 5.i0;  1.10;  1.10;  7.10;  20.10; 
27.3;  11.5 

12 

Olive  Road 

45 

21.9—^9.9;  21.9-^6.9;  22.9—25.9;  23.9—25.9; 
26.9—5.10;  26.9;  27.9— i.JO;  21.9—30.9;  28.9 
—30.9;  28.9—4.10;  29.9;  30.9—5.10;  6.10— 
15.10;  7.10;  29.9;  16.3—^^.5;  24.3— .27.5; 
15.4— i7.^;  29.4;  18.5— .25.-5 

13 

Sholapur  Street 

Shed 

21.9— .25.9 

14 

Broach  Street 

70 

22.9;  27.9;  21.9-28.9;  28.9;  10.4— iJ.^;  11.4 

15 

Bhandup  Street 

17 

22.9 

16 

Broach  Street  ... 

80 

25.9— .27.9;  2.4—10.4;  12.4—14.4;  24.4 

17 

Cullian  Street 

45 

26.9— J27.9;  2.10—4.10;  3.4—6.4;  2.5;  25.5— 
27.5;  12.6—13.6;  18.6—21.6 

18 

Broach  Street 

60 

26.9—27.9;  21.9—30.9;  17.10 

19 

Musjid  Station  Road... 

8-9 

26.9— J. iO;  26.9 

20 

.\rgyle  Road     ... 

56 

26.9—^9.9;  27.9—50.9;  7.10;  8.10— iO.iO;  8.4 

21 

Baroda  Street  ... 

80 

26.9;  27.9;  21.9—29.9;  29.9—2.10;  30.9—1.10; 
2.10;  24.10— .27.70 

22 

Bhandup  Street 

1-7 

27.9— ;28.9;  27.9  —  50.9;  28.9;  16.10— .25.i0; 
16.10— i9.20;  17.10;  15.3-^0.5;  22.3 

23 

Olive  Road       

39 

27.9— ;29.9;  4.10—4.10;  4.10 

24 

Do.               

33 

27.9;   1.10—4.10 

25 

Raichore  Street 

Shed 

28.9—30.9 

26 

Argyle  Road    

66 

28.9—18.10;  16.10—18.10;  18.10;  20.10— ~^5.i0 ; 
20.3—50.5;  21.5;  27.5 

27 

Do.              

2 

29.9— 4.iO;  6.10;  16.10;  17.10;  25.10— ,28.i0; 
27.10;  7.11-8.ii;  19.11—21.11;  16.3—20.3; 
1.4—3.4;  7.4;   13.4— i5.^;  16.4—17.4;   18.4; 

24.4—25.4 

190  Epidemiolofnj  of  Plague  [part  ii 

"  The  many  members  of  the  Scientific  Missions  I  have  taken  round 

the  citv  have  all  been  astonished  at  three  conditions  in 
The  three  •  ' 

conditions  in        **^^^"   *^''ty  : 

city  observed  (^,\     Xhe  size  of  the  buildings  and  the  number  of  the 

by  experts.  ,     ,-    •        •      ^, 

people  living  in  them. 

(6)     The  density  of  the  population. 

(c)     The  cleanliness  of  the  densely  populated  portions  of  the  city." 

To  quote  another  paragraph  in  the  report  of  the  Health  Officer : 

"  To  show  the   pitiful  condition  in  which  the  poor  classes  live  let 

us  enter  a  building  in  Khara  Talao  inspected  by  His  Excellency  the 

Governor.     There  is  a  ground-floor  and  a  room  above  it.     The  length 

of  the  ground-floor  room  is  111  feet  and  the  width  18^  feet.     There 

is  no  means  of  ventilation  on  either  side.     In  fact  the  room  is  a  passage 

with  a  door  in  front  between  closed  walls.     We  counted  in  this  room 

19  men,  20  women  and  17  children.     What  a  life  !     What  can  anything 

outside  this  room  do  for  the  people  in  their  misery  inside  ? " 

The  following  are   the   notes   made  by  the   author  of  a  morning's 

inspection  in  October  1897  in  another  district,  and  in  which  the  houses 

were  smaller  and  did   not  contain   such  large  numbers  of  inmates  as 

the  chawls.     It  will  be  seen,  however,  that  their  lack  of  light  and  air 

was  similar.     "  Met  the  Plague  Committee  at  the  Kama- 
Notes  of  a  ....  . 
morning's           tipuri  District,  where  it  had  been  decided  to  form  some 

inspec  ion.         search  parties  to  inspect  the  houses.    Each  search  party  was 

given  a  street  and  consisted  of  a  medical  man,  an  inspector,  a  native 

or  European  gentleman,  a  policeman,  a  man  with  a  lamp,  and  another 

with  a  bunch  of  keys.     There  was  one  lady  doctor  among  the  party. 

The    houses   were    taken  seriatim,  and  each   room    carefully  inspected 

and    the    inmates    examined.      The    people    took    to    the    search    very 

kindly,  and  there  was  no  difficult}'   whatever    experienced.     Many   of 

the  people  were  out  at  work  and  their  rooms  locked.      It  was  thought 

necessary  to  examine  these  and  the  man  with  the  bunch  of  keys  came 

into  requisition.     The  houses  in  the  Kamatipuri  District  are  of  a  very 

bad  type,  being  rather  deep  and  two  or  three  stories  high,  having  shops 

in  front  and  a  long  corridor  passage  from  front  to  back.     Into  this  dark 

corridor  open  small  rooms  which  are  windowless  and  enjoy  neither  light 

nor  air.     It  is  necessary  to  use  a  light  before  it  is  possible   to  say 

whether  the  room   is  occupied   or  not.     Behind   or  sometimes   in   the 

centre  of  this  corridor  is  the  latrine  for  the  house.     The  second  story 

is  as  dark  as  the  ground-floor  if  there  is  a  third  story.     As  the  houses 

adjoin  one  another  it  is  impossible  to  open  out  windows  into  the  open 


CH.  ix]  Conditions  in  Cape  Town  191 

air  either  for  light  or  for  ventilation,  and  the  only  remedy  appears  to 

be  the  pulling  down  of  every  other  house,  which  will  allow  windows  to 

be  opened  out  into  an  open  space  and  which  will  also  secure  ventilation. 

Two  cases  of  plague  and  one  suspicious  case  were  discovered  and  sent 

to  hospital." 

In  Cape  Town  plague  broke  out  at  a  time  when  the  town  contained 

many  refugees  on  account  of  the  Transvaal  war,  and  when 
Cape  Town.  jo 

a  large    number  of  natives   had   flocked   into    the    town. 

It  was  among  these  and  the  poorest  of  the  inhabitants  that  the  plague 
first  began  to  be  epidemic.  Cape  Town  for  its  size  has  a  very  large 
proportion  of  filthy  slums  and  insanitary  houses.  The  insanitary  houses 
and  areas  were  at  the  time  overcrowded  with  a  heterogeneous  popula- 
tion, consisting  of  natives,  coloured  people,  Indians,  Arabs,  and  whites 
of  almost  every  nationality.  The  natives  coming  direct  from  their 
kraals  in  the  native  territories  to  work  in  Cape  Town,  being  unused 
to  town  life,  are  unable  to  adapt  themselves  to  their  new  conditions 
and  crowd  together  when  permitted  to  an  extraordinary  degree.  In 
one  house  from  which  some  plague  cases  were  removed  65  natives 
were  secured  as  contacts,  but  over  30  escaped,  making  up  a  total  of 
nearly  one  hundred  persons  living  in  a  house  which  was  by  no  means  a 
large  one.  The  poorer  coloured  people  are  as  dirty  in  their  habits  as 
the  natives ;  the  Malays  and  Indians  possess  the  habits  of  the  Asiatic,  and 
the  poorer  class,  Portuguese,  Italian,  Levantine,  and  Polish  Jews,  which 
made  up  the  bulk  of  the  poor  white,  were  almost  as  filthy  as  the  others.  It 
was  accordingly  among  a  poor  and  crowded  population  living  in  a  very 
insanitary  state  in  ill-ventilated,  badly  lighted  and  rat-infested  houses 
that  the  plague  acquired  a  hold  upon  the  town.  The  majority  of  the 
whites  attacked  were  foreigners.  In  one  ward  of  the  plague  hospital 
out  of  16  patients  eleven  nationalities  were  represented.  The  distribu- 
tion of  plague  in  Cape  Town  followed  very  closely  the  distribution  of 
phthisis,  the  two  diseases  evidently  finding  in  the  insanitary  houses  and 
insanitary  habits  of  the  inmates  excellent  conditions  for  their  propaga- 
tion and  spread. 

Far  worse  from  a  hygienic  point  of  view  were  the  poorer  class  of 
houses  in  Port  Elizabeth,  where  plague  has  continued  to  recrudesce 
annually  since  its  first  appearance  in  1901. 

The  plague,  now  as  formerly,  is  largely  a  disease  of  the  poor,  and 

perhaps  falls  proportionally  more  heavily  than  any  other 

a  disease  of        infection  on  the  lower  strata  of  society.     At  one  time  it 

e  poor.  acquired  the  name  of  the  beggars'  disease,  at  another  the 

poor  plague,  and  at  another  miseriae  morbus. 


192  Epideniiologii  of  Plague  [part  ii 

Dr  Cabiadis  in  contrasting  the  immunity  of  Kcrbela  with  the 
prevalence  of  plague  in  Hillah  attributes  the  difference  to  the  pros- 
perous condition  of  the  inhabitants  of  the  former  •  place  \  even  the 
poorest  class  enjoying  a  meat  diet,  and  to  the  spacious  and  well-aired 
houses,  though  the  streets  are  narrow  and  crooked.  He  j)oints  out 
that  Hillah  is  the  very  reverse  of  this ;  its  houses  are  low,  confined, 
and  very  imperfectly  ventilated ;  they  are,  moreover,  generally  en- 
cumbered with  a  horse,  with  poultry,  and  with  two  or  three  buffaloes. 
These  animals  constitute  the  resources  whence  the  lower  classes  of 
Hillah  derive  a  livelihood  by  selling  milk  and  eggs  to  the  wealthier 
inhabitants,  while  they  themselves  limit  their  own  nourishment  to 
barley  bread,  dates,  and  onions,  with  sometimes  fish  in  a  putrescent 
state. 

The  following  is  a  description  of  a  Chinese  village  which  lost  nearly 
A  Chinese  half  of  its  inhabitants  from  plague  in  1902": — "  Sua-bui 

village.  jg    about   an    hour-and-a-half's    sail    from    Swatow.     The 

houses  are  clustered  together,  with  a  few  lanes  of  some  6  to  8  feet  in 
width  and  some  passages  not  more  than  4  feet  intersecting  the  village. 
Fronting  the  lanes  are  shops  and  houses  and  entrances  into  court-yards. 
The  shops  are  narrow,  obtaining  their  light  from  the  front.  The  houses 
in  many  instances  are  entered  direct  from  the  street  and  consist  of  one 
or  more  rooms  and  are  usually  devoid  of  other  means  of  light  than  the 
doors ;  sometimes  there  is  a  small  window  of  1  foot  in  length  by  9  inches 
in  breadth.  Other  entrances  give  access  to  a  small  court-^-ard,  around 
which  are  windowless  buildings  entered  by  separate  doors.  In  fine 
weather  the  inhabitants  when  not  out  in  the  fields  spend  most  of  their 
time  in  the  court-yard  or  the  street.  At  the  time  of  the  visit  the  garbage 
was  to  be  seen  heaped  up  almost  everj^where,  being  thrown  out  of  the 
house  and  left  to  the  disintegrating  forces  of  nature  and  of  the  pigs  and 
fowls.  Pigs  roved  or  lay  about  the  lanes  or  were  in  the  court-yard  or  in 
one  of  the  rooms  of  the  houses  with  the  fowls.  Calves  and  cows  were 
usually  tied  in  some  corner  of  the  lane  or  were  in  the  court-yard.  The 
drains  were  full  of  foul,  putrefying  black  mud  or  stinking  water  which 
could  get  no  outlet,  being  blocked  with  garbage.  Streets,  passages  and 
court-yards  were  a  mass  of  uncleanliness.  The  latrines,  however,  were 
well-built  reservoirs,  the  faeces  and  urine  being  valuable,  but  the  smell 
from  them  was  extremely  offensive.     Several  of  the  windowless  houses 

'  "  Supplement  containing  reports  and  papers  on  the  progress  of  the  Levantine 
Plague,"  by  Mr  Netten  Radcliffe.     Khitli  Annual  Report,  Load  Govt,  liuiird,  1879-80. 

^  "Eeport  on  the  causes  and  continuance  of  plague  in  Hongkong,  and  suggestions  as 
to  remedial  measures."     By  W.  J.  Simpson,  M.D.,  F.E.C.P.,  1903. 


CH.  IX J  Conclusion  193 

were  closed  because  their  inmates  had  fled  from  them  either  to  other 
villages  or  to  the  hills  to  escape  from  the  plague  which  had  been  in 
the  house.  Among  the  congeries  of  badly-lighted,  badly- ventilated,  and 
filthy  houses  there  were  a  few  to  be  seen  better  built,  better  lighted,  and 
cleaner.     They  were  the  exceptions  and  they  had  escaped  plague." 

It  is  an  interesting  observation  that  Macao  though  so  near  to  Hong- 
kong remains  comparatively  free  of  plague  after  its  first 
outbreak  there.  This  immunity  is  attributed  to  the  de- 
molition of  the  buildings  in  some  of  the  worst  areas  in  which  plague 
displayed  great  prevalence  and  malignity,  and  laying  out  in  their  place 
model  areas  containing  sanitary  buildings  with  an  abundance  of  light 
and  air  in  the  rooms. 

Social    conditions  connected  with   poverty,  misery,  deficient  or  ill- 
nutritious    food    and    overcrowding,    combined    with    the 
Conclusion.  .  •        i       •  i      i 

local  conditions  which  are  generally  associated  with  these, 

such  as  insanitary  dwellings,  which  are  dark,  damp,  dirty,  badly  lighted, 
dilapidated,  and  harbouring  rats  and  insects,  are  the  factors  commonly 
found  to  predispose  to  plague,  and  it  is  in  a  population  living  under 
these  social  and  local  conditions  that  plague  usually  commits  its 
greatest  ravages. 

Wherever  in  towns  there  is  the  greatest  overcrowding,  the  greatest 
crowding  together  of  buildings  on  the  smallest  areas,  and  consequently 
the  least  amount  of  fresh  air  and  sunlight  in  the  dwelling-rooms,  there 
plague  finds  a  home  from  which  it  is  difficult  to  be  dislodged.  Still  it 
has  to  be  recognised  that  insanitary  conditions,  although  they  render 
a  locality  a  suitable  nursery  ground  for  the  development  or  spread  of 
the  specific  agent  of  plague,  and  cause  the  population  to  become 
susceptible  to  the  disease,  do  not  appear  to  be  the  only  factors 
necessary  to  the  production  of  an  epidemic.  They  constitute  a 
favourable  soil,  but  before  the  plague  germ  can  fructify  to  any  great 
extent  in  that  soil  other  factors  must  come  into  play;  for  instance 
seasonal  influences  possess  a  very  marked  controlling  effect  on  the 
development  and  decline  of  plague  epidemics.  What  these  seasonal 
influences  embrace  and  the  conditions  they  produce  are  still  subjects  of 
speculation  rather  than  of  knowledge  acquired  by  investigation,  but  it 
is  certain  that  even  with  a  soil  receptive  of  plague  by  reason  of  its 
population  living  under  insanitary  conditions  the  plague  germ  once 
introduced  is  subject  to  seasonal  and  meteorological  influences  for  its 
development  and  spread,  and  in  different  places  it  has  to  await  these 
influences  before  it  makes  any  marked  progress. 

s.  13 


CHAPTER   X. 

DIFFUSION   AND   MODES   OF   DISSEMINATION. 

There  are  certain  laws  governing  the  diffusion  of  plague.  The 
infection  is  greatly  influenced  in  its  development  by  season  and  other 
factors,  but  however  ranch  this  may  be  it  requires  certain  carriers  for 
its  dissemination. 

The    bacillary    nature    of   the    infection    of  plague   permits    of  its 

transportability  by  means  of  certain  vehicles.     Living  for 
Plague  is  r  j      j  ^  _  " 

transportable,     a  time   in   the  human    being  or  animal    it    attacks,   the 

but  requires  |).^cillus  is  carried  wherever  the  human  being  or  animal 
certain  cam-  ... 

ers  for  its  dis-  goes ;  moreover,  capable  as  it  is  of  life  for  a  short  time 
semination.  ^^  j^^^^  outside  the  animal  body,  it  can  also  be  transported 
on  articles  that  have  been  contaminated  with  infected  secretions.  The 
infection  is  accordingly  transportable  by  these  vehicles,  not  only  from 
house  to  house,  but  also  from  town  to  town  and  country  to  country. 
Plague  prevalent  in  one  locality  may  be  carried  to  another  locality 
or  another  country  by  infected  human  beings,  by  infected  household 
effects,  by  infected  merchandise,  and  by  infected  animals. 

The  infection  is  observed  to  travel  generally  by  the  most  frequented 
piagTie  trade  routes.     The  pandemic  of  1348  entered  Europe  vid 

travels  by  Constantinople  and  was  brought   to   the  coast   towns  of 

frequented  the  Mediterranean  by  ships.     It  also  came  by  Tiflis  and 

trade  routes.  Armenia  into  Asia  Minor,  and  by  the  way  of  Mesopo- 
tamia into  Egypt.  In  the  subsequent  prevalence  of  plague  in  Europe 
during  the  14th,  15th,  16th,  and  17th  centuries  the  infection  frequented 
the  great  trade  centres.  While  Venice  and  the  Italian  States  were 
the  gateways  for  the  commerce  of  the  East  with  the  West  they 
were  subject  periodically  to  outbreaks  of  plague.  The  great  trade 
routes  from  Venice  to  the  north-west  of  Europe,  to  the  Baltic, 
and  to  the  North  Sea  were  not  by  sea  but  by  land,  through  Central 


CH.  x]  Conveyance  by  Sick  Persons  195 

Germany,  and  the  infection  was  conveyed  along  these  routes  to  the 
great  commercial  cities  of  the  Hanseatic  League,  and  from  these  spread 
in  various  directions.  The  Venetians  were  the  first  to  recognise  that 
the  infection  of  plague  could  be  transported  from  place  to  place,  and 
were  the  first  to  introduce  preventive  measures  against  its  introduction 
by  ships.  They  instituted  quarantine  in  1484  and  were  particularly 
solicitous  as  to  infection  in  merchandise. 

In  the  existing  pandemic  the  infection  has  been  carried  from  in- 
fected localities  over  the  seas  to  distant  ports,  from  Hongkong  to 
Bombay,  Japan  and  San  Francisco,  from  Bombay  to  Durban,  from 
Rosario  to  Cape  Town,  from  China  to  Mexico,  and  from  Mexico  to  Peru, 
and  many  other  distant  places.  As  in  the  pandemic  of  543  the  corn- 
ships  of  Egypt  carried  plague  to  Byzantium,  so  have  the  corn-ships  of 
modern  times  played  an  important  part  in  the  conveyance  of  plague 
to  healthy  ports.  The  infection  also  has  been  carried  overland,  as  in 
India  where  most  of  the  provinces  have  become  infected.  Sea-going 
ships  and  railways  in  recent  times  take  the  place  of  coasting  ships  and 
caravans  of  olden  days.  The  trade  routes  have  changed  with  maritime 
discovery  and  with  improved  methods  of  navigation,  and  coincidently 
Avith  this  alteration  plague  has  been  observed  to  be  diverted  from  its 
former  channels  of  extension.  The  Mediterranean  towns  have  not,  as 
formerly,  been  the  first  to  be  infected. 

It  is  generally  easier   to   observe  the   mode  by  which   infection  is 

carried  from  an  infected  locality  to  some  distant  place  than  to  trace 

the  various  modes  by  which  the  disease  is  disseminated  in  an  infected 

town.    Instances  are  numerous  of  persons  incubating  or  sick  with  plague 

fleeing'  from  a  plague  centre,  taking  the  infection  into 
Persons  sick  o  i     o  o 

or  incubating  distant  villages  or  ports,  and  there  setting  up  new  centres 
the^fection  ^^  ^^^  disease.  The  most  dangerous  types  of  plague  for 
to  other  the    dissemination    of  the    disease    in    this   way  are    the 

pneumonic  and  septicaemic;  and  it  is  not  an  uncommon 
occurrence  for  the  inmates  of  a  house  to  be  one  after  the  other 
attacked  by  plague  after  the  arrival  of  a  relative  or  friend  who  is 
either  suffering  from  or  falls  ill  within  a  few  days  with  one  of  these 
forms  of  plague.  Villages  in  China  and  India  were  frequently  infected 
in  this  way. 

For  inland  towns  and  villages,  separated  some  considerable  distance 
from  an  infected  centre,  human  agency  is  the  most  commonly  observed 
mode  of  dissemination  from  one  locality  to  another.  In  an  enquiry 
made  by  Captain  James,  I.M.S.,  into  the  source  of  infection  of  some  of  the 

13—2 


196  Epidemiolofiji  of  Plague  [part  ii 

Puiijiiub  villages  he  found  that  out  of  G3  villages  no  fewer  than  47  or  a 
percentage  of  73  were  infected  by  the  arrival  of  infected  persons,  and 
much  the  same  ])roportion  probably  holds  good  for  other  inland  places. 
A  similar  ex])erienco  falls  to  most  investigators.  Captain  Browning 
Smith,  I.M.S.\  in  a  recent  report  on  plague  in  villages  in  the  Amritzar 
district,  remarks  that  "  in  the  great  majority  of  villages  infection  could 
be  traced  to  human  intercourse  between  healthy  and  infected  villages, 
and  this  is  doubtless  the  manner  in  which  the  disease  spreads  from 
village  to  village,  the  usual  history  being  that  a  person  went  to  an 
infected  village  to  visit  relatives  attacked  with  the  disease  or  to  be 
present  at  the  funeral  ceremonies  of  dead  relatives;  on  return  to  the 
healthy  village  the  person  develops  plague :  the  next  step  was  the 
infection  and  death  of  rats  in  the  infected  and  adjoining  houses,  followed 
by  a  rapid  spread  of  the  epidemic  plague  occurring  in  those  houses  and 
parts  of  the  village  in  which  rats  died."  This  is  the  usual  sequence 
except  in  pneumonic  cases  when  infection  takes  place  without  the 
customary  rat  infection.  The  following  two  instances  recorded  by 
Captain  Browning  Smith  may  be  mentioned. 

(1)  Pneumonic  plague.  At  Munda  Dina  a  Jullah  returned  from 
the  infected  village  of  Bagrian  on  26th  January,  1903,  attacked  on 
27th  January,  died  the  same  day,  and  fifteen  members  of  the  family 
died  of  pneumonic  plague.  The  epidemic  was  pneumonic  and  only 
lasted  a  short  time  and  did  not  spread,  for  the  last  case  occurred  on 
8th  February,  1903.     No  rats  were  seen  dead  during  the  epidemic. 

(2)  Bubonic  plague.  On  7th  March,  1903,  Mela  a  Jullah  returned 
from  Nagoke  and  was  taken  ill  on  the  13th,  and  died  the  same  day 
of  bubonic  plague ;  rats  began  to  die  on  10th  March,  in  the  houses 
adjoining,  and  the  first  case  after  Mela  occurred  in  them  on  14th 
March.  The  epidemic,  which  lasted  till  29th  May  and  caused  174 
cases  with  144  deaths,  was  of  the  bubonic  type. 

It  is   not  always  persons   ill  or  about  to  be  ill    with   plague   who 

create  new  foci  of  the  disease  in  healthy  localities.    Healthy 

so^ns  some"        persons  from  an  infected  house  are  able  at  times  to  carry 

times  carry        ^^g   infection    without   being   infected   themselves.     The 
the  infection.  ...  i  •    j 

Hifection  m  these  circumstances  appears  to  be  carried  on 

the  clothes  or  personal  effects  of  the  traveller  or  refugee. 

Major  Anderson  gives  some  specific  instances  of  this  kind  to  the 

Indian  Plague  Commission. 

I  "  Report  on  plague  and  inoculation  operations."  By  S.  Browning  Smith,  Capt.  I.M.S. 
Indian  Medical  Gazette,  June,  1904. 


CH.  x]  Conveyance  hi/  Infected  Clothes  197 

"  In  Agashi  the  first  local  case  occurred  in  the  person  of  a  Shimpi 
woman  at  whose  house  some  friends  from  Bombay  had  come  to  live. 
None  of  these  Bombay  people  were  sick  or  were  afterwards  attacked.  In 
Kelwa  also  the  first  local  cases  occurred  in  the  persons  of  two  Shimpis 
to  whose  house  some  Shimpis  from  Bombay  had  come  five  days  before. 
These  Bombay  people  were  in  good  health,  and  after  staying  three 
days  returned  to  Bombay....  At  Verso va  a  striking  instance  of  the 
disease  being  carried  by  an  apparently  healthy  person  occurred.  The 
first  imported  case  at  Versova  occurred  on  30th  January  in  the  person 
of  a  Brahmin  who  came  sick  from  Bombay.  The  Brahmin  school- 
master of  Versova  visited  this  man  while  he  was  sick,  and  attended 
his  funeral  on  31st  January.  The  schoolmaster  lived  in  the  village 
Talati's  house.  On  the  2nd  February  the  Talati's  nephew  who  lived 
in  this  house  was  attacked  by  plague,  while  the  schoolmaster  himself 
was  not  attacked  till  the  5th  of  February. 

"  In  Marol  also  the  first  case  occurred  in  a  house  to  which  a  number 
of  people  had  come  from  Bombay  to  attend  a  wedding.  These  people 
were  in  good  health  and  after  staying  some  days  they  returned  to 
Bombay  in  good  health.... 

"  Again,  in  the  village  of  Madhan,  an  isolated  case  occurred  prior  to 
the  outbreak  there,  in  the  person  of  a  man  at  whose  house  a  man  from 
Bombay  had  come  to  live^" 

In  these  cases  the  agent  by  which  the  infection  is  transported  by 

the  healthy  person  can  only  be  a  matter  of  conjecture.     In  other  cases, 

however,    the    agent    is  definite    enough.      In    one    of  the    villages    of 

Fukien,  South  China,  a  girl  brought  home  a  bundle  of 

transported        clothes   from   a  plague   village.     In  a   week    or    so    most 

and  dissemi-       virulent  ijlague  broke  out  in  the  house  and  nine  people 
nated  by  ^      ^  _  .  •  i  i 

infected  died  in  that  house  alone  ^.    Plague  in  1900  was  nitroduced 

clothes.  ^^^.^   Durban   from    the   Mauritius   by  infected   clothing. 

A    boy   from   the   Mauritius,  in    order  to  avoid    detention  at   Durban 

owing  to  quarantine,  proceeded  with  his  family  to  East  London,  from 

which  port  he  afterwards  embarked  for  Durban,  landing  there  on  April 

1st      On  the  13th  of  May  he  unpacked  part  of  his  luggage  and  two 

days  later  was  attacked  with  plague,  dying  on  the  third  day  of  his  illness. 

In  September,  1890,  two  Goanese  sailors  from  Bombay  were  attacked 

by  plague  in  London  a  fortnight  after  the  ship's  arrival,  and  at  least 

*  Report  of  the  IndUin  Phujue  Comvmsion,  Vol.  v.  chap.  iii.  pp.  100  and  107. 
■•'  Appendix  to  the  Report  on  the  Cmnfes  and  Continuance  of  I'lagiie  in  Hongkonfj,  1903. 
By  W.  J.  Simpsou,  M.D. 


198  Epidemiolo(i]i  of  Plague  [part  ii 

37  days  after  leaving  Bombay.  It  appeared  to  the  Medical  Officer  of 
the  Local  Government  Board  who  enquired  into  the  circumstances  that 
the  probable  cause  of  the  infection  was  the  wearing  of  clothes  that 
during  the  voyage  had  been  stowed  away  in  one  or  other  of  the  men's 
chests  and  only  brought  out  after  the  ship's  arrival  in  London'. 

A  sweeper  from  Chinkoa,  an  infected  village  in  the  Punjaub, 
worked  in  Kulewal,  in  the  house  of  a  person  who  died  of  plague.  The 
sweeper  received  as  a  present  some  of  the  patient's  clothes.  He  took 
them  home  to  his  non-infected  village  and  gave  some  of  them  to 
a  neighbour.  This  neighbour  was  attacked  by  plague  shortly  afterwards 
and  he  appears  to  have  been  the  first  person  who  developed  plague  in 
Chinkoa-. 

Three  men,  some  of  whose  friends  had  died  from  the  plague  in 
Bombay,  arrived  at  Ahmedabad  from  that  city  and  stayed  for  three  days 
at  the  house  of  a  relative  outside  the  city  wall.  They  then  proceeded 
to  Kadi,  their  village  in  the  Baroda  State,  leaving  some  of  their  clothes 
behind  them  in  the  house  at  which  they  had  stopped.  Three  days 
after  their  departure,  plague  cases  occurred  in  the  room  which  they  had 
occupied.  The  three  men  were  traced  to  Kadi,  kept  under  observation, 
but  remained  quite  well^ 

At  another  village,  Akhada,  some  people  returned  from  Bombay, 
bringing  with  them  various  goods  and  chattels.  A  few  days  later  two 
of  the  friends  with  whom  they  were  staying  were  stricken  with  plague. 
The  visitors  remained  in  good  health*. 

The  infection  was  introduced  into  Rajapur  in  the  Ahmednagur 
district  by  a  Marwari  from  Sirar,  whose  brother  had  died  of  plague  and 
who  presented  the  clothing  of  the  deceased  to  a  family  of  Mahars, 
of  whom  five  caught  the  infection  and  died^ 

Many  of  the  plague  cases  in  the  villages  of  China  are  attributed  by 
medical  men  there  to  the  practice  of  the  Chinese  wearing  the  clothes  of 
persons  who  have  died  of  plague.  The  same  dangerous  custom  used  to 
exist  among  the  Mahommedans  of  Turkey  and    Egypt    when    plague 

1  rwenty-sixth  Annual  Report  of  the  Local  Govt.  Board.    "  Report  of  tlie  Medical  Officer 
for  1896-97." 

2  Ileport  of  the  Indian  Plague  Commission,  Vol.  v.  chap.  iii.  p.  111. 

*  Ibid,    and  Report    of  the    Epidemic   of    Plague    in    the   Bombay   Presidencu.      By 
J.  A.  Lowson,  M.B.,   1897. 

*  Report    of    the    Epidemic    of    Plague    in     the    Bombay    Presidcncu.       By    J     A 
Lowson,  M.B.,  1897. 

5  A    History    of   the   Progress   of    Plague    in    the    Bombay    Presidency.      By    Capt. 
J.  K.  Condon. 


CH.  x]  •  Period  of  Greatest  Danger  199 

prevailed  in  these  two  countries  and  was  considered  to  be  a  very  potent 
means  for  the  diffusion  of  the  disease.  Another  example  of  transport- 
ability of  plague  infection  in  clothes  may  be  cited.  It  is  that  of  the 
epidemic  at  Eyam  in  1665,  when  plague  was  imported  from  London 
during  the  month  of  September  into  this  remote  village  away  among 
the  hills  of  the  Derbyshire  Peak.  The  village  is  150  miles  from  London, 
not  a  great  distance  in  these  days  of  railways,  but  little  accessible  then. 

Early  in  the  month  of  September,  when  plague  was  at  its  worst  in 
London,  there  was  sent  to  George  Vicars,  a  tailor,  a  box  of  clothes. 
He  opened  the  box  and  hung  the  clothes  to  the  fire  and  the  account 
states  he  became  violently  sick  and  ill.  On  the  second  day  he  was 
worse,  was  delirious  at  intervals,  and  large  swellings  appeared  on  his 
neck  and  groin.  On  the  third  day  the  plague  spot  was  on  his  breast 
and  he  died  the  following  night.  In  the  course  of  a  year  the  plague 
thus  introduced  into  the  village  attacked  76  families  and  destroyed  267 
out  of  350  inhabitants,  or  79  "/o  of  the  population^ 

The  infection  imported  by  infected  persons  or  by  infected  articles  of 

clothing  may  not  be  transmitted  direct  to  man  but  may  be 

conveyed  to  a     ^"^^  often  is  conveyed  first  of  all  to  the  rats  in  the  house, 

new  centre  these  rodents  being  attacked  with  plague.     In   this  way 
may  affect  p-?-         •  i-,i  • 
rats  before  a  new  centre  oi  miection  is  set  up  which  later  is  trans- 
human  fgJ.J.g(J       ^Q      J^J^JJ 

beings. 

A   man   lost    his    wife    in    Bombay    from    plague    and 

10  days  later  started  for  his  native  village  near  Hurnai,  taking  with  him 

his  wife's  clothes.     About  a  week  after  his  arrival  in  his  village,  which 

until  then  was  quite  free  from  plague,  the  rats  in  his  house  and  in  its 

vicinity  began  to  die,  and  shortly  afterwards  five  of  his  relatives  living 

in  the  house  and  who  had  never  been  out  of  the  village  were  one  after 

the  other  attacked  with  plague  and  died.     Lastly  the  man  himself  was 

attacked  with  plague  and  later  there  was  an  outbreak  of  plague  in  the 

village. 

Every  epidemic  causes  a  certain  amount  of  uneasiness  and  alarm  at 

Additional         ^^^  commencement,  leading  to  flight  of  the  inhabitants,  but 

risk  of  ex-         as  the  cases  are  not  then  numerous  the  infection  has  little 
tension  from  ,  c    ^     •         ■  ,     i     ■    ,  i       i  i        ,        ,  •   • 

an  infected         chance  ot    being  imported   into  many  healthy  localities. 

locauty  Then  as  the  plague  is  found  to  only  slowly  progress  there 

height  of  an       springs  up  a  feeling  of  security,  the  panic  abates  and  the 
epi  emic.  exodus,  for  the  time  being,  ceases.     Later  a  change  in  the 

progress  of  the  epidemic,  manifested  by  a  sudden  and  rapid  increase, 
'  Public  Health,  p.  95.     By  William  A.  Guy,  M.B.,  F.R.S.,  1870. 


200  E2)idemi()lo(i!i  of  Plague  [part  ti 

leads  to  renewal  of  the  panic  on  a  mcjre  exaggerated  scale  and  to  a  fresh 
flight  of  the  inhabitants  compared  with  which  the  first  flight  was  insigni- 
ficant. Crowds  leave  the  infected  locality.  This  time  the  infection 
among  the  refugees  is  much  more  disseminated.  Large  numbers  leave 
with  the  infection  on  them,  either  already  developed,  developing,  or 
about  to  develop  into  the  most  virulent  types  of  the  disease.  The 
chances  of  sowing  the  seeds  of  infection  in  new  places  by  human  agency 
at  this  stage  of  the  epidemic  are  therefore  greater  than  at  any  other 
time.  The  greater  danger  attaching  to  the  second  flight  appears  not  to 
be  so  much  connected  with  the  greater  virulence  of  the  disease,  and 
hence  its  greater  tendency  to  spread,  nor  because  of  the  early  cases  in 
an  epidemic  being  unable  to  create  new  centres  of  infection  when 
transported  to  healthy  localities  in  which  the  conditions  are  favourable, 
but  because  the  later  cases  that  flee  to  new  districts  in  a  rapidly  rising 
epidemic  are  much  more  numerous  and  accordingly  the  chances  of 
failure  of  engrafting  themselves  on  new  centres  are  fewer. 

In  the  event  of  an  outbreak  of  plague  in  a  port  the  infection  is  not 
only  carried  inland  to  towns  and  villages  by  road  and  rail,  but  it  is  also 
carried  by  boats  and  ships  to  neighbouring  and  distant  ports.  At  the 
time  that  plague  was  epidemic  in  Bombay,  refugees  were  occasionally 
found  ill  on  the  principal  roads  leading  fi'om  the  city,  also  in  the  railway 
carriages  and  at  the  railway  stations.,  where  a  system  of  inspection  was 
instituted.  Many  towns  and  villages  close  to  Bombay,  and  a  few  at  a 
great  distance,  had  cases  of  plague  imported  into  them.  Cases  came  by 
rail  even  as  far  as  Calcutta.  This  repeats  itself  in  connection  with 
every  new  centre  of  plague:  thus  in  1902  no  fewer  than  176  cases  were 
withdrawn  from  the  railway  trains  at  Jalarpet^  the  point  where  cases 
from  the  Mysore  territory  are  received.  The  exodus  from  Bombay  was 
by  sea  as  well  as  by  land,  and  boats  and  coasting  steamers  carried 
plague  patients  to  neighbouring  ports.  When  plague  was  epidemic  in 
Canton  the  people  who  fled  carried  the  infection  into  the  villages  far 
and  near,  many  of  them  never  reaching  their  homes  but  dying  on  the 
way ;  and  those  who  fled  in  boats  to  Hongkong  brought  the  infection 
into  the  Colony.  The  same  occurrences  repeated  themselves  in  Hong- 
kong, when  plague  became  epidemic  there,  and  were  res[)()nsible  for  the 
infection  of  many  of  the  ports  of  Southern  China,  for  in  the  flight  of  the 
inhabitants  on  boats  and  coasting  steamers  the  infection  of  plague  was 
carried  wherever  they  went.  In  one  of  these  flights  in  1901  in  the 
course  of  five  weeks  no  fewer  than  160  persons  were  detected  by  the 

'    Tliirlij-niiitli  Report  of  the  Sanitdri/  Coiiunissioiier  fur  Madras  for  1902,  p.  15. 


CH,  x]  Transporl  hy  Armies  201 

Custom  House  Officers  as  suffering  from  plague  on  the  steamers  arriving 
at  Canton  from  Hongkong,  and  35  passengers  were  during  the  same 
time  found  dead  of  plague.  These  steamers  were  crowded  with  pas- 
sengers and  destined  for  short  distances.  In  the  case  of  long  voyages 
greater  care  is  usually  taken  to  prevent  sick  persons  from  embarking, 
and  there  are  usually  not  the  same  crowds  leaving  the  infected  port. 
Fewer  cases  consequently  occur  on  these  ships  and  there  is  less  likeli- 
hood of  sick  persons  carrying  the  infection  to  a  distant  port.  Yet, 
though  the  chances  are  greatly  reduced,  ships  from  infected  ports 
occasionally  arrive  after  long  voyages  with  persons  on  board  suffering 
from  plague.  The  illness  is  not  among  refugees,  for  of  the  latter,  as  a 
rule,  there  are  none,  but  it  is  generally  among  the  crew  or  sailors  of  the 
ship  or,  occasionally,  a  passenger  is  attacked.    A  few  instances  will  suffice 

to  exemplify  the  long  distances  the  infection  may  be  carried 
carried  long  by  ships.  The  s.s.  Boi^mida  arrived  at  Bombay  in  March, 
distances  in        1899,  from  Hongkong  with  a  Chinese  cook  suffering  fi-om 

plague.  The  s.s.  Kilharn  arrived  in  Cape  Town  in  1900 
from  Rosario  in  the  Argentine  with  the  captain  and  several  of  the  crew 
stricken  with  plague.  The  s.s.  Highland  Mary  arrived  in  Liverpool  in 
1900  from  Buenos  Ayres  after  a  voyage  of  32  days  with  a  seaman 
suffering  from  plague.  The  s.s.  Ben  Lomond  arrived  at  London  in 
1900  from  Cebu  in  the  Philippine  Islands  after  a  voyage  of  59  days  with 
one  of  the  engineers  affected  with  plague.  Almost  every  country  which 
has  commercial  relations  with  infected  ports  can  furnish  instances  of  the 
arrival  of  ships  with  plague  cases  on  board.  A  full  account  of  those 
ships  which  arrived  in  England  with  cases  of  plague  on  board  from 
189G  to  1901  is  given  by  Dr  R.  Low  in  the  reports  and  papers  on 
bubonic  plague  and  issued  by  the  Local  Government  Board  in  1902. 

Next  to  the  migration  of  })anic-stricken  people  from  infected  centres 
Transport  of       movements  of  crowds  from  infected  areas,  whether  it  be  of 

infection  faci-  armies,  pilgrims,  coolies,  or  emigrants,  facilitate  the  trans- 
litated  by  the  .  .  o  > 

movements  port  of  mfection.  The  spread  of  plague  in  Syria  was 
of  crowds.  frequently   connected    with    the    march   of  armies,  which 

had  become  infected.  The  Arabian  army  in  639  is  stated  to  have 
lost  25,000  men  from  the  disease  and  to  have  been  the  means  of 
spreading  the  infection.  Two  commanders-in-chief  died  of  the  plague, 
after  which  Abu  Obeida  removed  his  troops  from  the  towns  and 
distributed  them  in  the  highlands,  with  the  result  that  the  plague 
was  successfully  overcome.  Similarly  in  Mesopotamia  and  Persia,  the 
aienas  so  often  of  conflicts  and  of  the  marching  and  counter-marching 


202  Epidemioloff}!  of  Plague  [part  ii 

of  armies,  the  infection  was  carried  to  and  fro  and  epidemics  set  up  in 
fresh  localities.  Later,  infection  was  carried  by  the  Crusaders  who,  in 
turn,  had  received  the  infection  from  the  Saracens.  The  Thirty  Years' 
War  in  Europe  was  a  period  of  plague  prevalence  among  the  inhabitants 
of  the  countries  in  which  it  was  waged,  the  different  armies  carrying 
the  infection  from  place  to  place.  In  1632,  when  the  opposing  armies 
of  Wallenstein  and  Gustavus  Adolphus,  King  of  Sweden,  numbering 
some  111,000  men,  encamped  close  to  Nuremberg,  having  a  population 
of  its  own  of  50,000  and  which  was  considerably  increased  by  refugees, 
plague  broke  out  in  July  and  in  seven  weeks  30,000  of  the  town 
inhabitants  perished  and  each  of  the  two  armies  is  recorded  as  losing 
one-third  of  its  effective  strength.  In  the  following  year,  1633, 
Schweidnitz  in  Silesia  suffered  from  the  encamping  of  two  armies  in 
its  neighbourhood.  Of  24,000  inhabitants  it  is  stated  to  have  lost 
16,000,  i.e.  two-thirds,  while  the  Imperialist  army  lost  8000  out  of 
30,000  of  its  troops,  or  more  than  one-fourth,  and  the  Swedes  lost 
12,000  out  of  25,000,  or  nearly  one-half^.  Plague  has,  in  more  modern 
times,  been  spread  by  Turkish  armies  in  Hungary  and  the  region  of  the 
Balkans.  The  epidemic  of  Moscow  in  1771,  which  cost  that  city  60,000 
of  its  inhabitants,  is  attributed  to  infection  being  carried  into  the  town 
by  Turkish  prisoners  of  war  and  Russian  soldiers  returned  from  the  war 
then  being  waged  between  Turkey  and  Russia.  M.  Rocher  in  describing 
the  spread  of  plague  in  1870  and  1871  in  the  province  of  Yunnan 
draws  attention  to  the  infection  being  carried  to  different  towns  by 
infected  troops. 

It  is  not  always  infected   persons  or  infected  clothes   that  spread 
the  infection  of  plague.     In  the  South  African  War  the 

Transport  .  ■       ^    n        n      ^•  ^ 

of  infection  immense  transport  required  for  feeding  the  army,  and  a 

™  w  les^^  portion  of  which  was  brought  from  infected  countries,  was 

other  than  the   means    of  introducing  the   infection   into  the  South 

persons  or  African  ports.     Plague  broke  out  at  Cape  Town  and  Port 

infected  Elizabeth  where  fodder  and  grain,  brought  from  Rosario 

clothes.  .        .  .         Ti      1  1        ,  1  •    ,.         ,       .  , 

in    Argentina,   Bombay,  and    other   places    infected  with 

plague,  were  stored  in  large  quantities.     The  infection  was  evidently'- 

imported  with  the  produce,  either  by  means  of  infected  rats  or  infected 

material,  which  set  up  an  epizootic  among  the  local  rats  which  in  turn 

infected  the  inhabitants. 

For  ships  to  be  a  danger  to  the  port  at  which  they  arrive  it  is  not 

'  La  Pexte  en   AUemagne  pendant    la   premiere  moitie   du   dix-septieme  sieclc.      Par 
E.  Charv^rat.     Lyons,  1892. 


CH.  x]  Transport  by  Shijis  203 

necessary  that  plague  rats  on  board  ship  should  infect  any  of  the  crew 
or  passengers  on  the  voyage.  Not  infrequently,  though  some  of  the 
rats  on  board  are  infected,  there  is  no  human  sickness  on  the  ship,  and 
vice  versa,  when  there  are  a  few  cases  of  plague  on  board  among  the 
passengers  or  crew  there  may  be  no  infection  of  the  rats.  In  the  course 
of  two  months  in  one  year  the  rats  on  7  out  of  14  ships  arriving  in 
Marseilles  from  an  infected  port  were  found  to  be  infected.  Kossel  and 
Nocht  also  found  dead  rats  on  board  two  vessels  arriving  in  port  in  which 
no  human  cases  of  plague  had  occurred,  and  there  is  one  instance  of 
a  vessel,  the  s.s.  Rembrandt,  arriving  at  Bristol  in  which  plague  rats 
were  discovered  on  board  without  any  plague  among  passengers  or  crew. 
The  risk  to  the  port  on  account  of  the  arrival  of  these  ships  was  none 
the  less  dangerous  because  all  the  passengers  were  found  to  be  in  a  good 
state  of  health.  No  special  measures  of  prevention  were  taken  at  the 
Cape  with  regard  to  ships  arriving  fi-om  infected  ports  with  fodder 
on  board  as  long  as  there  were  no  sick  persons  on  board  or  no  history  of 
plague  during  the  voyage.  The  practices  pursued  in  regard  to  such 
ships  were  the  same  as  elsewhere  and  were  in  conformity  with  the 
prevalent  views  at  the  time  of  human  agency  being  not  only  the  most 
important  but  the  sole  carrier  of  the  infection,  in  contradistinction  to 
the  older  and  no  doubt  also  exaggerated  views  of  a  couple  of  centuries 
ago  that  merchandise  was  the  chief  danger.  It  is  becoming  clearer 
every  day  that  the  doctrine  of  human  agency  as  the  only  conveyer  of 
infection  on  ships  arriving  from  infected  ports  is  incorrect,  and  that  the 
modern  view  must  be  modified  in  the  light  of  actual  experience,  which 
is  that,  notwithstanding  the  few  cases  of  human  plague  detected  among 
passengers  from  infected  ports,  yet  there  is  the  fact  that  plague  spreads 
from  port  to  port.  It  has  to  be  recognised  that  different  diseases  have 
often  different  modes  of  dissemination,  and  that  which  may  be  true  and 
applicable  to  one  is  not  so  to  another.  Some  diseases,  no  doubt,  are 
transportable  on  ships  from  one  country  to  another  solely  by  human 
agency,  and  by  human  agency  is  included  not  only  sick  persons  but  also 
their  personal  effects,  but  so  far  as  plague  is  concerned  it  is  in  a  different 
category  and   the   infection   can  be  transported  bv  other 

IllSt3.IlC6S  of  cj       c/  It/ 

infection  means.     It  was  in  the  great  storage  depots  and  sheds  in 

being  con-  ^^le    docks    at    Cape    Town    and    in    the    vicinity    of  the 

nected  with  .  . 

cargoes  and        immense   stacks  of  fodder  in    the   neighbourhood  of  the 

wharves  in  Port  Elizabeth  that  the  rats  began  to  die  of 
Cape  Town.  .  °  . 

plague,  and  it  was  subsequent  to  this  rat  mortality  that 

the  workmen  connected  with  these  shipments  and  storage  depots  were 


204  Epidemiolofiii  of  Plague  [part  ii 

first  attacked  with  plague.     In  1901  a  quantity  of  military  stores  and 

merchandise  which  had  been  lying  at  Cape  Town  was  taken  by  sea  to 

Mossel  Bay,  a  small  town  on  the  south  coast  between  Cape  Town  and 

Port  Elizabeth.     Soon  after  the  landing  of  the  shipments  the  rats  began 

to  die  in  the  neighbourhood  of  the  landing  jetty  of  Mossel 

Bay,  folhnved  by  a  number  of  cases  of  plague  among  the 

inhabitants,    all    f)f  which   were   traced   to   rat  infection.     Apart   from 

military    operations    plague    may    be    similarly    introduced    under    the 

conditions    of    ordinary    maritime    commerce.     In    East 
East  London.  ^      k  c  ■  \.     n  ■     ^• 

London,  South  Africa,  the  first  indication  of  infection  was 
the  death  in  February,  1902,  of  rats  in  a  shed  close  to  the  wharves 
receiving  goods  from  Durban  where  plague  prevailed.  The  rat  mortality 
from  plague  spread  in  the  neighbourhood,  after  which  there  were  cases  of 
human  plague  associated  with  rat  infection.  Plague  is  credited  with 
being  re-introduced  much  in  the  same  way  into  the  port  of 
Durban  in  December,  1902,  when  the  rats  in  a  limited 
area  of  the  harbour  frontage  were  attacked  with  plague,  and  a  resident 
was  soon  afterwards  attacked  with  plague  on  the  premises  where  the 
rats  were  dying.  On  the  18th  of  November  the  s.s.  Kassala  brought 
a  large  consignment  of  Lucerne  hay  from  the  Argentine,  a  portion 
of  which  was  delivered  to  the  premises  on  which  the  rats  first  began  to 
die.  For  the  first  two  months  the  majority  of  the  cases  of  plague  were 
satisfactorily  traced  to  infection  in  the  shipping  area  and  were  principally 
associated  with  rat  infection. 

The  part  which  merchandise  takes  in  the  conveyance  of  infection 
from  one  port  to  another  is  difficult  to  gauge.  It  is  associated  so 
closely  with  the  role  that  the  rats  on  board  may  play  when  plague- 
stricken,  that  the  separation  and  consideration  of  the  two  factors  apart 
from  one  another  are  seldom  possible. 

Theoretically  it  is  not  impossible  for  merchandise  to  carry  infection, 
for  the  bacillus,  once  getting  on  to  textile  material,  may  live  and  retain 
its  virulence  for  a  considerable  period,  but  there  is  no  instance  in  which 
it  has  been  absolutely  demonstrated  that  merchandise  unconnected 
with  its  usual  association  with  infected  rats  has  been  responsible  for 
an  outbreak  of  plague.  The  detection  by  Kitasato  of  the  plague 
bacillus  on  cotton  goods  consigned  to  a  mill  in  Osaka, 
in  which  plague  broke  out  after  receipt  of  the  goods, 
shows  that  the  danger  may  be  a  real  one,  though  it  is  difficult  to  prove. 
The  soiling  of  merchandise  by  infected  rats  may  account  for  the  fact 
that  men  employed  in  discharging  cargo  have  fallen  ill  after  sleeping 


CH.  x]  Transport  by  Infected  Merchandise  205 

on  bales  or  on  empty  sacks,  and  may  also  explain  one  of  the  means  bv 
which  local  rats  become  infected. 

Dr  J.  S.  Low',  who  was  Medical  Officer  on  plague  duty  in  Cape 
Colony,  cites  an  instance  of  plague  being  probably  caused  by  handling 
infected  goods.  It  was  in  Port  Elizabeth,  where  a  European  had 
occasion  to  unpack  a  bale  of  goods  at  his  warehouse,  after  it  had  come 
from  the  docks  where  many  plague  rats  had  been  found.  A  rat,  proved 
bacteriologically  to  have  died  of  plague,  was  found  among  the  goods, 
and  four  days  after  the  man  was  attacked  by  plague.  The  only  source 
of  infection  at  all  probable  is  stated  to  have  been  the  handling  of  the 
infected  goods,  and  Dr  Low  remarks  that,  had  the  bale  gone  up  country, 
it  is  possible  it  might  have  furnished  the  first  indigenous  case  at  its 
destination. 

The  infection  at  Bhujpur,  a  village  of  Cutch,  was  attributed  by  the 

authorities  to  infected  ffunny  bags,  the  plague  breakinsf 
Bhujpur.  .  r.T?-iii 

out  m  the  house  of  a  Banniah  who  brought  gunny  bags 
from  Bombay  for  sale.  He  was  attacked  on  the  31st  July,  1898,  and 
two  other  Banniahs  also  who,  it  is  said,  bought  gunny  bags  from  him  for 
the  storing  and  export  of  grain.  As  there  was  then  no  communication 
with  Bombay  by  sea  owing  to  the  monsoon,  the  Banniah  had  been  in 
Bhujpur  for  at  least  two  months  before  being  attacked  with  plague. 
There  is,  however,  the  possibility  of  trade  relation  with  Mandvi,  where 
plague  prevailed,  and  that  Bombay  was  not  the  actual  source  of  in- 
fection -. 

Bombay,  Sydney,  Oporto,  Naples  and  other  places  are  believed  to 
have  received  their  infection  from  infected  rats  on  board  of  ships 
arriving  from  infected  ports.  In  the  majority  of  ports  it  has  been 
observed  that  without  any  known  entrance  of  sick  persons,  and  without 
any  history  of  illness  occurring  among  recent  arrivals,  the  first  signs  of 
the  disease  have  been  an  outbreak  of  plague  among  the  rats  on  the 
quays,  or  in  the  immediate  vicinity  of  the  docks,  and  that  it  was  among 
the  employees,  where  the  rats  were  dying,  that  the  first  cases  of  plague 
were  discovered. 

Plague  appears  to  have  been  imported  in  1903  into  Pisco,  one  of  the 

ports  of  Peru,  by  a  vessel  bringing  corn  from  Mazatlan, 

where  there  were  at  the  time  many  cases  of  plague.     The 

epidemic  among  men  was  preceded  by  an  epizootic  among  rats.     In  the 

middle  of  April  many  dead  rats  were  found  in  the  neighbourhood  of  the 

^  Encyclopaedia  Medica,  Vol.  xiii.  p.  562. 
■^  Indian  Plague  Commission,  Vol.  ii.  p.  213. 


200  Epidemiologif  of  Plague  [part  ii 

Custom  House,  and  the  first  individuals  attacked,  three  in  number,  were 

employed  as  sweepers  in  that  place.    In  the  fourth  case  the  infection  had 

not  this  origin,  but  was  probably  acquired  from  one  of  the  former,  whom 

he  had  nursed  during  his  short  illness  and  whose  dead  body  he  laid  out 

and  accoinpanied  from  San  Andres  to  Pisco ^ 

Callao  is  suspected  to  have  been  infected  in  a  similar  fashion,  but  it 

was  impossible  when  the  outbreak  was  enquired  into  to 
Ca.lla.0 

trace  the  origin  of  infection.     Attention  was  first  attracted 

to  the  fact  that  in  the  middle  of  April,  1903,  numbers  of  rats  were  seen 

sick  and  dead  in  various  parts  of  Callao- ;  first,  in  the  mill  of  Santa  Rosa ; 

secondly,  in  the  principal  station  of  the  English  railway ;  thirdl}',  in  one 

of  the  rooms  of  the  municipal  buildings;  finally  in  the  upper  stories  of 

the  International  Hotel.     This  phenomenon  was  noticed  synchronously 

in    these    different    places.     In    the    mill    of  Santa    Rosa   an    unusual 

mortality  of  rats  was  noticed  for  about   15  days,  which  produced  an 

insupportable    stench    in    the    different    floors    and    divisions    of    the 

establishment,  including    the   garden,  so    much    so,  that   in   the  room 

where  the  sacks  were  stored  the  odour  became  so  offensive  that  before 

opening  the  door  it  was  necessary  to  hold  the  breath  and  then  to  depart 

instantly  in  order  to  let  in  fresh  air  before  entering.     The  number  of 

dead  rats  in  this  mill  was  estimated  at  300. 

The  first  case  occurred  on  the  28th  of  April  in  the  person  of  Pedro 
Digueroa,  an  employee  of  the  mill  of  Santa  Rosa,  who  died  on  May  1st. 

In  the  night  of  the  29th  of  April  Emilio  Klapp,  also  a  labourer  at 
the  mill,  was  attacked,  and  died  on  the  6th  of  May.  On  the  night  of 
the  30th  of  April  Pascual  Novelli,  a  companion  of  the  above,  and  on  the 
1st  of  May  Miguel  Cornejo,  also  of  the  mill,  fell  ill,  and  died  on  the 
7th  inst.  On  the  2nd  of  May  Pedro  Castro,  a  painter,  who  had  worked 
at  the  mill  from  the  21st  of  April,  fell  ill  with  the  same  symptoms.  On 
the  3rd  of  May  Manuel  Feubi,  a  Chinese  cook  employed  by  the  overseer 
of  the  mill,  was  taken  violently  ill  and  died  in  72  hours.  The  same  day 
Samuel  Gonzalez,  also  a  labourer  at  the  mill,  fell  ill  and  died  after 
a  prolonged  struggle  on  the  29th  of  May.  On  the  4th,  Juan  Fernandez, 
and  on  the  7th,  Alfredo  Valela  and  Juan  Ramirez,  all  employees  of  the 
mill,  were  attacked,  and  the  first  died  on  the  29th  of  May. 

Thus  in  the  course  of  ten  days,  i.e.  from  the  28th  of  April  to  the  7th 

^   "  Gaceta  de  los  Hospitales,  Civiles  y  Militares,"  15th  Feb.  and  1st  March,  1904. 

-  "  La  Peste  Bubonica.  Informe  presentado  a  la  Academia  Nacional  de  Medicina,  por 
la  Comision  especial  encai"gada  de  estudiar  la  compuesta  por  los  mierabros  titularen,  Dr 
Manuel  K.  Artoth,  Dr  Julian  Arce,  y  Dr  Daniel  E.  Lavoreria." 


CH.  x]  Rats  and  Mercliandise  207 

of  May,  ten  employees  of  the  mill  of  Santa  Rosa  fell  sick,  with  60  "/o  of 
deaths  amongst  the  attacked.     The  mill  was  closed  on  the  8th  of  May. 

Further  enquiry  elicited  the  fact  that  suspicious  cases  of  plague  had 
occurred  in  Callao.  In  February  or  March  of  1903  Cesar  Silva,  a 
servant  of  Mr  Weiss,  station-master  of  the  English  railway,  fell  sick 
with  fever  and  double  inguinal  adenitis,  without  specific  cause,  and  was 
treated  in  the  paying  wards  of  the  hospital  of  Guadeloupe,  whence  he 
was  discharged  cured  in  about  20  days.  At  the  end  of  March  Jose 
Aguilard,  employed  at  the  station,  was  attacked  with  high  fever  and 
a  glandular  swelling  in  the  left  axilla,  which  suppurated  and  was  opened, 
and  had  besides  a  painful  swelling  of  the  left  inguinal  glands.  The 
Commission  reporting  on  the  outbreak  regarded  these  two  cases  as 
being  probably  either  Pestis  minor  or  Pestis  ambulans. 

The  plague  at  Asuncion,  the  capital  of  Paraguay,  is  stated  to  have 
Asuncion  been    brought   on   a   river  steamer,  the   s.s.    Centauro,  to 

which  at  Montevideo  bags  of  rice  had  been  transhipped 
from  the  sailing  vessel  the  Zeir,  which  in  turn  had  received  the  rice  at 
Rotterdam  from  a  vessel  arriving  from  an  Indian  port.  On  the  Zeir's 
arrival  at  Las  Palmas,  dead  rats  were  found  among  the  sacks  of  rice, 
and  afterwards  on  the  voyage  two  sailors  fell  ill,  one  of  them  dying 
suddenly.  During  the  voyage  of  the  Centauro  from  Montevideo  to 
Asuncion,  dead  rats  were  found  on  the  ship,  and  three  of  the  sailors 
died  from  diseases  which  were  considered  at  the  time  to  be  pneumonia, 
typhoid  fever,  and  pleurisy.  A  fortnight  after  the  arrival  of  the 
Centauro,  there  was  a  mortality  among  rats  in  the  custom-house 
premises  at  Asuncion.  This  mortality  spread  over  different  parts  of 
the  town,  and  was  later,  by  bacteriological  examination,  established 
to  be  due  to  plagued 

The  plague  at  Unsie,  a  city  in  China,  was  traced  by  Dr  J.  P.  Maxwell 
to  the  arrival,  from  the  plague-infucted  port  of  Swatow,  of 

Ulisi6  AC?  X 

a  boat  on  which  there  were  plague-infected  rats.  About 
the  middle  of  April  of  1902,  a  junk  with  rats  dying  on  board  arrived  at 
Unsie.  Shortly  after,  rats  began  to  die  in  that  portion  of  the  town 
which  adjoins  the  quay,  and  on  May  2nd  or  3rd  plague  broke  out  in 
the  house  of  a  man  who  resided  some  250  yards  from  the  quay.  Dead 
rats  were  found  in  the  house  about  a  fortnight  previously  -. 

Plague  on  board  ship,  while  the  vessel  is  in  a  plague-infected  port, 

1  Annales  de  Vlmtitut  Pasteur,  No.  ii. ,  1901,  p.  8.57. 

-  Appendices  to  the  Report  on  the  Causes  and  Continuance  of  Playue  in  Hongkong.     By 
W.  J.  Simpson,  M.D.,  1903. 


208  Epidemiolog!/  of  Plague  [part  ii 

or  after  its  departure  from  such  a  port,  ascribed  to  the  rats  on  the  ship 

having  become  infected  by  some  means,  has  happened  sufficiently  often 

for  such  an  occurrence  to  be  reckoned  as  one  of  the  risks  which  is  run 

by  a  ship  lying  in  an  infected  port. 

Inland  towns  sometimes  OAve  their  infection  to  the  importation  of 

rats    infected    with    plague    or   rat-infected    merchandise. 

sometlmesTn-     Especially  has  this  been  observed  in  Cape  Colony.     Graaf- 

fected  by  con-     Reinet,  King  William's  Town,  Kei  Road  and  Burghersdor]) 

raUway  of  were    infected    in    this    manner.       Dr    J.    A.    Mitchell, 

rats  infected      Assistant    Medical    Officer    of    Health    for   the    Colony, 
with  plague  .  i      •  i       p 

or  rat-in-  reporting  on  these  observations  states  that,  during  the  first 

chandi^^"^"  week  of  February  of  1903,  plague-infected  rats  were  found 
in  the  railway  station  premises  at  Graaf-Reinet,  that  some 
time  previously  a  large  quantity  of  forage  and  military  supplies 
principally  from  Port  Elizabeth  had  been  stored  in  the  immediate 
vicinity  of  these  premises,  and  that  later  an  epizootic  of  plague  occurred 
among  the  local  rat  population.  Again,  on  the  7th  March,  four  cases  of 
plague  were  almost  simultaneously  discovered  among  the  employees  at 
the  railway  goods  shed  at  King  William's  Town.  No  dead  rats  had 
previously  been  observed  but  during  the  disinfection  of  the  premises 
several  mummified  rats  and  mice  were  discovered ;  owing  to  their 
condition  it  was  impossible  to  determine  the  cause  of  death  but  there 
appears  to  have  been  little  doubt  that  they  died  of  plague.  Plague- 
infected  rats  and  several  cases  of  plague  were  discovered  later  in 
different  parts  of  the  town.  Again,  a  number  of  dead  rats  in  a  state  of 
decomposition  too  far  advanced  to  admit  of  a  definite  diagnosis  being 
made  as  to  the  cause  of  death,  were  discovered  in  the  railway  premises 
at  Kei  Road,  and  four  days  afterwards  a  case  of  plague  occurred  in  the 
station-master's  wife.  During  the  process  of  disinfection  of  the  premises 
the  carcases  of  a  considerable  number  of  rats  dead  of  plague  were 
discovered.  In  regard  to  Burghersdorp  an  apparently  healthy  rat  was 
caught  at  the  railway  station  and  subsequently  killed  and  examined. 
Bacilli  apparently  identical  with  those  of  plague  were  found  on  micro- 
scopical examination  of  the  remains  and  the  diagnosis  of  plague  was 
subsequently  confirmed  by  inoculation  experiments.  The  railway 
premises  were  then  disinfected  but  no  dead  or  sick  rats  were  discovered 
during  the  process.  Subsequently  a  number  of  dead  mice  were  found  in 
forage  stored  near  the  railway  station  and  specimens  from  these  were 
found  on  examination  to  contain  plague  bacilli.  Dr  Mitchell  makes  the 
following  pertinent  remarks  on  this  subject : 


CH.  x]  Rats  and  Merchandise  200 

"A  number  of  instances  has  been  observed  where  live  rats  have 
come  ashore  from  vessels  or  have  been  carried  long  distances  by  rail  or 
otherwise  in  bales  of  forage,  or  in  'skeleton'  or  partially  open  crates. 
Sick  rats  are  probably  more  likely  to  remain  in  a  bale  of  forage  or  in 
a  crate  of  merchandise  during  transport  than  healthy  ones.  Again, 
a  rat  suffering  from  plague  may  enter  and  die  in  a  bale  of  forage  or  in 
a  'skeleton'  crate  and  thus  be  carried  long  distances  by  sea  or  rail.  The 
carcase  remains  infectious  for  a  considerable  period.  On  the  arrival  of 
the  bale  or  crate  at  its  destination,  local  rats  are  likely  to  investigate  its 
contents,  perhaps  devouring  the  carcase  of  the  dead  rat  and  thus 
becoming  infected.  Or  again,  bales  of  forage  or  open  or  '  skeleton ' 
crates  containing  fi'uit,  hardware,  or  similar  goods  packed  in  straw  or 
other  material  of  a  like  nature,  if  stored  at  a  place  where  plague  exists 
among  the  rats,  may  be  infected  by  their  discharges,  and  if  subsequently 
removed  to  another  locality  are  liable  to  transmit  the  infection  to  the 
rat  population  of  the  latter.  It  is  practically  certain  that  plague 
infection  has  been  conveyed  inland  to  Graaf-Reinet,  King  William's 
Town,  Kei  Road,  and  Burghersdorp  in  one  or  other  of  these  three 
ways." 


14 


CHAPTER   XL 

MODES   OF   DISSEMINATION   IN   AN    INFECTED   LOCALITY. 

It  is  recognised  that  the  pneumonic  type  of  plague  is  distinctly  and 

directly    infectious.     Medical    men   and    nurses   have   fre- 

type  of  quently  been  attacked  while  attending  on  patients  suffering 

plague  in-  from  this  variety  of  the  disease,  whereas  it  is  rare  for  them 

ffiptiioiis 

to  contract  plague  from  patients  suffering  from  the  septi- 
caemic  or  bubonic  form.  The  sputum  of  a  pneumonic  plague  patient 
teems  with  virulent  bacilli  which,  in  the  act  of  coughing,  may  be  trans- 
mitted a  short  distance  through  the  air.  Nurse  Macdougall  in  Bombay 
attending  to  a  patient  suffering  from  pneumonic  plague  received,  during 
a  fit  of  coughing  on  the  part  of  the  patient,  a  particle  of  plague  sputum 
in  the  eye,  which  next  day  set  up  conjunctivitis  followed  by  swelling  of 
the  parotid  and  cervical  glands  and  an  attack  of  plague  to  which  she 
succumbed.  Surgeon-Major  Manser  of  Bombay  contracted  pneumonic 
plague  of  which  he  died  by  attending  a  patient  suffering  from  this  form 
of  the  disease,  and  Nurse  Joyce  who  nursed  him  was  attacked  on  the 
evening  of  the  third  day  by  pneumonic  plague  and  died  in  two  days. 
Dr  Mueller  of  Vienna  and  Nurse  Pecha  contracted  pneumonic  plague 
while  attending  on  Barisch,  the  laboratory  attendant  who  received  his 
infection  while  working  among  the  infected  laboratory  animals.  In  Cape 
Town,  Miss  Kayser,  the  lady  superintendent  of  the  Plague  Hospital, 
contracted  pneumonic  plague  from  a  patient,  and  after  a  few  days' 
illness  died  :  the  day  after  her  death  her  sister,  who  had  nursed  her,  was 
taken  ill  and  died  of  pneiimonic  ])lague. 

The  occurrence  t)f  ])neumonic  cases  in  a  town  is,  as  a  rule,  traceable 
to  personal  contact  with  jjatients  affected  with  this  form  of  the  disease 
and  the  history  is  generally  one  of  the  disease  spreading  in  the  track  of 
relations  and  fi'iends  who  have  visited,  and  who  have  come  into  close 
relationship  with  the  patient.  The  source  of  pneumonic  plague,  although 
frequently,  is,  by  no  means,  always  derived  from  an  antecedent  case. 


CH.  xi]         Pnemnonic  Plague  directly  infectious  211 

This  is  exemplified  by  the  occasional  cases  of  pneumonic  plague  which 
arise  among  persons  in  the  laboratory.  The  history  of  most  of  these 
cases  is  that  the  persons  attacked  have  been  dealing  with  infected 
animals  and  the  disease  has  most  probably  been  contracted  from  these 
animals.  The  mode  of  conveyance  of  the  infection  might  easily  be 
the  hand  which  has  become  infected  by  handling  a  plague-stricken 
rat  and  which  has  been  accidentally  raised  to  the  nose,  thereby  infecting 
the  nasal  mucous  membrane.  It  may  be  in  such  instances  that  the 
type  of  the  disease  in  the  infecting  animals  is  pneumonic,  but  this  has 
yet  to  be  established. 

To  a  similar  source,  viz.  infected  animals,  may  occasionally  be  traced 
the  first  in  a  series  of  pneumonic  cases  occurring  in  an  infected  locality, 
the  first  case  generally  arising  in  a  house  in  which  a  large  number  of 
rats  have  died.  The  author  has  observed  this  in  a  number  of  cases. 
Once  established  as  pneumonic  plague  the  infection  breeds  true,  for 
some  time  giving  rise  to  pneumonic  cases,  but  later  it  fails  to 
reproduce  itself  in  this  form  and  is  propagated  as  a  septicaemic 
or  bubonic  type.  The  Indian  Plague  Commission^  give  in  their  report 
a  genealogical  table,  constructed  from  material  furnished  them  by 
Surgeon-Major  Green  of  the  Indian  Medical  Service,  which  exhibits  the 
very  remarkable  power  of  pneumonic  plague  giving  rise  to  pneumonic 
plague  fi-om  patient  to  patient  through  no  fewer  than  five  consecutive 
series.     The  table  is  reproduced  on  page  212. 

On  the  other  hand  experience  shows  that  pneumonic  cases  give  rise 
to  bubonic  cases  both  when  contracted  under  the  ordinary  condition  of 
natural  infection  and  also  under  accidental  circumstances  such  as  a 
post-mortem.  There  are  several  cases  on  record  in  which,  owing  to  an 
accidental  wound  in  the  hand  when  performing  a  post-mortem  on 
a  pneumonic  case  of  plague,  plague  of  a  bubonic  type  has  been  con- 
tracted. There  is  a  case  also  reported  in  which  a  patient  delirious 
with  pneumonic  plague  bit  a  compounder  at  Hubli  on  the  thumb,  who 
afterwards  suffered  from  a  mild  attack  of  plague  with  an  axillary  bubo. 

The  infectivity  of  septicaemic  and  of  bubonic  cases  which  become 

„    ^.  septicaemic  before  death  is  not  to  be  iudged  by  the  rarity 

Septicaemic  ...  j      n  j  j 

piagne  in-  with  which  medical  men  and  nurses  contract  plague  when 

attending  such  cases  in  hospital.  If  that  were  the 
standard  the  conclusion  arrived  at  would  be  that  the  powers  of  in- 
fection were  feeble  instead  of  being  as  they  are  extremely  potent.     The 

'  Report  of  the  Indian  Flngue  Commission,  Vol.  v.  p.  91. 

14—2 


•212 


Epidi'iuloloffn  of  Plaf/ue 


[part  II 


ORIGINAL   SOURCE   OF   INFECTION    IN    THE    HOUSE   OF    KAVIRAJ 
DWARKA   NATH    IN   CALCUTTA. 


r 
1 

I 

1 
1 

2 

3 

4 

1  ■ 

1 

5 

Kedar  Nath 

Basanta  Kumar                  Madhu  Sudan 

Sita  Nath 

Bishnadi 

Bhattacharji 

Das 

Bliattacharji 

died  Calcutta 

Brahmacl 

died  Calcutta 

died  Calcutta                     died 

Calcutta 

31/8/98 

died  Cha 

16/8/98 

23/8/98                                29/8/98 

'        1 

31/8/91 

1 
1 
6 

1 
1 

7 

i 
1 
8 

1 
1 
9 

1 
1 
10 

1 
II 

Dr  Amulaya 

Shashi  Bhusan 

Upendra  Nath 

Girija  Prosanna 

Puddomoni, 

Compoundei 

Chann  Bose, 

Sen 

Eai, 

Raj, 

servant  in  house 

attendee 

who  attended 

attended  on 

nephew  of  Girija, 

in  whuse  house 

where  Sita  Nath 

Bishnadu 

Sita  Nath, 

Sita  Nath, 

died 

Sita  Nath  lived, 

lived, 

died 

died  Calcutta 

died  Calcutta 

Backergunge 

died  Backergunge         died  Calcutta 

Chausa 

4/9/98 

•4/9/98 

4/9/98 

5/9/98 

i 

1 

6/9/98 

6/9/98 

r 

12 

1 
13 

Tarak 

, 

Binodini, 

servant  of  ( 

Sirija,                    wi 

fe  of  Girija, 

died  Backer 

gunge 

died 

5/9/98 

Backergunge 

1 

12/9/98 

14 

Lakhi  Some, 

brother-in 

-law 

of  Tarak,  visited 

Tarak  and  died 

Backergunge 

9/9/98 

1 

1 

1 

15 

16 

17 

18 

Mukta, 

Ramnidhi, 

Ramani, 

Baikuntha 

visited 

assisted  at             w 

ife  of  Lakhi  Some, 

lived  in  Tarak's 

Lakhi  Some, 

Lakhi  Some's 

nursed  him,  died 

house,  nursed 

died                   cremation,  died 

Backergunge 

Lakhi  Some  and 

Backergimge 

Backergunge 

17/9/98 

cremated  him,  died 

16/9/98 

16/9/98 

1 

Harsundari, 

Backergunge 
17/9/98 

1 
20 

w 

ife  of  Ramnidhi 

Kamini, 

nursed  him,  died 

wife  of  Baikuntha, 

Backergunge 

nursed  him,  died 

22/9/98 

Backergunge 
23/9/98 

CH.  xi]  Si  tuple  Bubonic  Plague  not  directly  infectious    213 

conditions  of  home  life  under  which  plague  generally  occurs  and  the 
conditions  of  nursing  in  a  small,  ill-lighted,  and  badly- ventilated  room 
by  relatives  and  friends  are  in  quite  a  different  category  from  those 
existing  in  hospitals.  Under  the  conditions  of  the  home  the  general 
distribution  of  the  plague  bacillus  in  the  blood,  internal  organs,  and 
excretions  in  septicaemic  cases  renders  them  dangerously  infective, 
especially  when  discharges  are  wiped  away  by  the  hands  or  with  the 
clothes  of  the  attendants.  Plague  bacilli  escape  from  the  body  in 
septicaemic  cases  in  the  secretions  and  discharges  of  the  mucous 
membranes,  gaining  an  exit  by  the  mouth  and  nostrils,  bowels  and 
kidneys.  If  the  plague  patient  is  not  removed  to  hospital,  secondary 
cases  usually  follow  independently  of  other  indirect  means  by  which 
the  disease  may  spread  in  a  house. 

Undertakers  and  those  who  lay  out  the  dead  are  apt  to  contract 
the  disease.  In  Hongkong  many  of  the  undertakers  perished,  and  there 
is  a  general  impression  among  the  Chinese  that  the  corpse  is  more 
dangerous  than  the  patient.  Attendance  at  funerals,  especially  when 
connected  with  feasting  or  ceremonial  rites,  is  often  dangerous,  plague 
afterwards  affecting  those  who  have  been  present.  Two  of  the  earlier 
cases  in  the  Glasgow  outbreak  of  1900  were  traced  to  attendances 
on  a  "  wake "  on  the  occasion  of  a  child  and  its  grandmother  having 
died  of  plague  but  whose  deaths  were  certified  to  be  "zymotic  enteritis" 
and  "  acute  gastro-enteritis'." 

On  the  other  hand  bubonic  plague  which  remains  simple  bubonic 

Simple  l)lague  is  not  directly  infectious  even  under  conditions  of 

bubonic  home  life  and  it  seldom  affects  the  relatives  and  friends 

plague  not  .      .  ..... 

directly  in   immediate  and   intimate  association  with  the  patient. 

infectious.  j^  -g  |^^  ^^  means  certain  that  bubonic  cases,  even  of  the 

Pestis  ambulans  type,  are  not  indirectly  infectious  though  the  manner 

in  which  the  infection   leaves  the   body  and  the  agency  by  which  it 

spreads  are   still  only  matters  of  speculation.     Captain  James  of  the 

Indian  Medical  Service  instances  the  village  of  Gobindpur  in  the  Punjaub 

which  he  sets  down  as  having  become  infected  by  the  arrival  of  a  boy 

suffering  from  Pestis  ambulans.     The  person  living  next  door  to  this 

boy  in  the  same  enclosure  was  attacked  with  a  severe  form  of  plague. 

Among  indirect  means  of  dissemination  of  plague,  infected  clothes 

have  a  share.     How  lar^e  that  share  is  it  is  difficult  to 
Dissemma-  ... 

tion  by  in-  estimate;    it  probably  varies  in  different   epidemics  and 

fected  clothes.  i         ^■n>  ,      •  ^  mi  ^  r 

under  dmerent  circumstances.       I  he  custom  oi  removing 

^  "Eepoit  on  certain  Cases  of  Plague  occurriug  iu  Glasgow  in  1900."     By  tlie  Medical 
Officer  of  Health. 


214  Epidemiolociji  of  Plar/ue  [part  ii 

as  many  articles  as  possible  fi-om  an  infected  house  is  probal)ly  more 

common  and  more  skilfully  carried  out  amcmg  Asiatic  people  wherever 

they  may  be  than  among  Europeans.     It  often  happens  that  by  the 

time  the  health  officials  hear  of  the  death  and  arrive  at  the  infected 

house,  most  or  a  great  many  of  the  portable  household  articles  have 

disappeared.     In  Cape  Town  there  was  much  secret  disposal  of  effects 

when  Malays  wei'e  attacked,  but  the  practice  was  not  limited  to  them. 

It  is  remarkable  how  adherent  the  infection  may  remain  among  the 

different   members   of  a  family  and   its  branches,  the  infection  being 

discovered  in   many  instances  to  be  associated  with  the  surreptitious 

disposal  and  removal,  from  house  to  house,  of  effects  which  have  not 

been    subjected    to    disinfection.      It    was    noticed    in    India    that    the 

incidence  on  the  Dhobies  or  washermen  was  exceptionally  heavy. 

Plague-stricken  rats  must  also  be  included  as  one  of  the  indirect 

modes  of  dissemination  of  the  disease  in  a  locality.     The 
Dissemma-  -^  _ 

tion  by  association  of  epizootics  of  plague  among  rats  with  epi- 

ec  e  ra  s.  fi^iyjicg  of  plague  has  already  been  referred  to  as  having 
been  observed  in  many  important  epidemics  of  plague.  In  fact  as 
regards  modern  plague  since  1894  there  has  been  no  great  prevalence 
in  any  part  of  the  world  without  also  an  epizootic  among  rats. 

As  opportunity  for  observation  has  arisen  in  the  different  epidemics 
in  different  places  the  part  which  this  epizootic  takes  in  the  dissemina- 
tion of  plague  has  been  discovered  to  be  exceptionally  powerful. 
Certain  observers  have  gone  so  far  as  to  declare  that  with  the 
exception  of  pneumonic  plague  propagated  by  direct  contagion  all 
other  forms  of  plague  are  disseminated  by  the  rat.  This  is  an  extreme 
view  which  like  many  extreme  views  though  containing  much,  perhaps 
the  greater  portion,  that  is  correct,  does  not  represent  the  whole  truth. 
It  is  interesting  to  note  that,  though  dogs  and  cats  were  considered 
to  be  dangerous  both  on  account  of  their  suffering  from  plague  and 
their  carrying  infectious  material  on  their  coats,  nowhere  does  the  part 
which  the  rat  has  been  observed  to  play  in  the  dissemination  of  plague 
appear  to  have  been  recognised  in  the  same  light  as  during  this 
pandemic.  The  phenomenon  of  rat  mortality  was  taken  as  a  sign  of 
a  coming  plague  or  that  plague  was  a  soil  disease  and  that  these  ground 
animals  became  first  affected  with  plague,  rather  than  that  the  rats 
themselves  were  dangerous. 

Hankin  and  Simonds  in  1898  summarised  in  the  Annaiesde  I'histitut 
Pasteur  the  facts  which  had  then  been  observed,  and  came  to  the 
conclusion  that  rats  played  an  important  part  in  the  dissemination  of 
the    disease.     This  conclusion   was  the   same  as  tliut  which  had  been 


CH.  xi]  Disseminafi'on  hi/  Rat^  215 

arrived  at  by  many  with  practical  experience  of  plague.  Since  that 
time  there  has  been  ample  opportunity  of  verifying  its  correctness. 

The  great  influence  which  plague-stricken  rats  exercise  in  the 
dissemination  of  the  disease  comes  prominently  into  notice  in  those 
towns  and  places  where  plague  cases  are  removed  to  hospital  with 
promptitude,  and  where  the  infected  clothes  are  disinfected,  and  yet  the 
epidemic  continues  to  develop.  Such  has  been  the  case  in  Cape  Town, 
Port  Elizabeth,  East  London,  Durban  and  other  towns  in  South  Africa, 
and  also  in  Brisbane  and  Sydney  in  Australia. 

Special    value  attaches    to   the   observations   in    South   Africa   and 

Australia,  because  the  history  of  each  case  was  more 
Special  value  .  "^ 

attaches  to         readily  traceable  than  m  Eastern  countries.     The  spread 

tfons^irsoutii  ^^  plague  in  the  towns  of  South  Africa  and  Australia  was 
Africa  and  associated  principally  with  the  course  of  the  plague  epi- 

zootic  among  rats,  the  direct  infection  from  human  being 
to  human  being  and  the  indirect  infection  communicated  by  infected 
clothes  having  been  eliminated  by  the  action  of  the  sanitary  adminis- 
tration. 

In  Cape  Town  not  only  were  the  first  cases  in  the  docks  associated 
with  the  rat  mortality  and  traceable  to  it,  but  the  progress  of  the 
disease  in  its  later  phases  was  notably  connected  either  with  the  move- 
ment of  rats  from  infected  centres,  which  resulted  in  the  setting  up 
of  new  foci  of  disease,  or  with  the  infection  of  rats  in  new  centres  by 
other  modes  than  the  migration  of  rats.  As  regards  the  latter  mode, 
a  block  of  houses  was  infected  by  bringing  to  one  of  its  houses  bales 
of  goods  from  the  docks.  Whether  these  bales  of  goods  contained 
infected  rats  at  the  time  of  their  removal  from  the  docks,  or  were 
infected  in  the  docks  themselves  by  the  discharges  from  plague  rats, 
it  is  impossible  to  say,  but  the  conveyance  of  these  goods  to  a  healthy 
part  of  the  town  infected  the  local  rats.  On  the  discovery  of  infection 
of  the  rats  all  the  houses  but  one  were  evacuated.  The  single  exception 
was  left  because  there  was  no  available  accommodation  in  the  health 
camp.  In  a  short  time  plague  attacked  the  inmates  of  the  house,  Avhile 
the  others  who  had  been  removed  to  camp  remained  unaffected.  In 
Cape  Town  it  was  possible,  by  bacteriological  examination  of  the  rats 
brought  in  from  different  parts  of  the  town,  to  trace  in  a  general  way 
the  course  of  the  plague  epidemic,  for  it  corresponded  with  that  of  the 
epizootic. 

The  majority  of  cases  of  plague  were  traceable  to  infection  from  rats, 
dead  or  infected  rodents  being  found  at  the  residences  and  workshops 


216  Epidemioloffii  of  Plague  [part  ii 

of  those  attacked  with  the  disease.  The  number  occasionall}'  found 
under  the  floors  of  infected  premises  was  extraordinary,  notwithstanding 
the  absence  of  the  signs  of  sick  or  dead  rats  on  the  surface  of  the 
premises.  In  one  house  there  were  as  many  as  105  rats  discovered  by 
the  cleansing  department,  in  another  52,  and  in  the  majority  one  to 
half-a-dozen.  There  were  houses  in  which  no  rats  were  found  and 
in  many  of  these  cases  the  source  of  infection  was  traced  to  other 
causes. 

The  same  intimate  association  of  plague-stricken  rats  with  plague 
in  man  and  the  relationship  of  cause  which  the  fonner  bore  to  the 
latter  were  traced  in  Port  Elizabeth,  East  London,  Durban  and  other 
towns  invaded  with  plague. 

Two  interesting  features  about  the  epizootic  among  rats  in  Port 
Elizabeth  are  worthy  of  mention.  The  first  is  that  the  epizootic  has 
never  been  so  severe  as  that  which  prevailed  in  Cape  Town,  and  the 
second  is  that  it  has  continued  in  a  more  or  less  sporadic  form  since 
its  commencement.  Similarly,  the  epidemic  of  plague  has  not  been 
of  a  very  severe  character  and  has  continued  in  a  more  or  less  sporadic 
form.  There  are  evidently  different  degrees  of  severity  and  rapidity 
of  diffusion  of  plague  among  rats  as  there  are  differences  in  this  respect 
in  epidemics  of  plague  in  different  localities.  Apparently  when  the  rats 
are  much  infected  and  over  a  wide  area  in  a  locality,  the  epidemic  in 
man  is  correspondingly  wide  and  severe,  but  when  the  rats  are  only 
sporadically  attacked  the  disease  in  man  is  also  sporadic. 

The  history  of  the  epidemics  in  S^Tlney  in  1900  and  1901,  and  in 
Brisbane  in  1901  and  1902,  which  agrees  in  many  respects  with  that 
of  South  Africa,  and  w  hich  establishes  both  in  time  and  place  the  close 
relationship  existing  between  the  incidence  of  rat  plague  and  the 
subsequent  occurrences  of  human  plague,  demonstrates  the  very  im- 
portant share  Avhich  rat  plague  takes  in  the  dissemination  of  human 
plague,  and  the  very  small  part  that  human  intercourse  sometimes 
plays  in  the  local  diffusion  of  the  disease. 

In  the  Hongkong  epidemic  of  1902  hundreds  of  rats  were  daily 
examined  bacteriologically,  and  it  was  found  that  the 
Si*Hongkong-  P''*2^6"ce  of  plague-infected  rats  in  a  house  or  locality 
meant,  sooner  or  later,  if  immediate  measures  of  precaution 
were  not  taken,  cases  of  plague  in  that  locality  or  house,  and  that 
the  dissemination  of  the  plague  by  rats  was  even  a  more  influential 
factor  in  the  spread  of  the  disease  than  its  dissemination  by  man.  By 
an  examination  of  the  rats  it  was  possible   to   plot  out  the  localities 


CH.  xi]  Dissemwation  by  Rats  217 

which  were  likely  to  remain  healthy  and  those  in  which  plague  cases 
might  be  expected.  It  was  observed  in  Hongkong  that  the  rat  plague 
would  occasionally  pass  along  a  number  of  houses  on  one  side  of  the 
street  and  then  suddenly  pass  over  to  the  other  side.  A  similar 
phenomenon  has  been  observed  in  different  epidemics  of  plague  in 
human  beings,  and  there  is  reason  now  to  suppose  that  the  explanation 
of  this  peculiar  course  of  plague  is  to  be  found  in  the  movements  of 
infected  rats.  To  turn  now  to  a  few  specific  instances.  In  1901  30 
men  were  employed  in  Hongkong  to  collect  rats,  and  no  fewer  than 
nine  or  80  "/„  died  of  plague,  three  others  leaving  the  Colony  sick. 
In  a  piivate  firm  of  30  coolies  employed  in  sorting,  and  one  of  whose 
duties  was  to  collect  dead  rats  from  the  godown  when  required,  five  or 
16'6"/o  contracted  plague  and  died.  In  another  firm  rats  were  dying 
in  the  store-room  and  two  men  engaged  in  removing  them  were 
attacked  with  and  died  of  plague.     There  are  similar  examples  to  these 

mentioned  by  Hankin  and  Simonds  in  the  Bombay  epi- 
m  india*^°'^^      demic.     Hankin  records  a  case  of  this  kind  in  a  mill  in 

which  there  were  several  thousands  of  workmen.  Rats  were 
noticed  to  die  in  large  numbers ;  20  coolies  were  employed  to  remove  the 
dead  rats;  out  of  the  20  no  fewer  than  12  were  attacked  by  the  plague, 
while  the  rest  of  the  workmen  and  others  in  the  building  remained 
healthy.  Simonds  also  records  an  example  of  rat  infection  in  two 
women  caused  by  handling  dead  rats.  The  inhabitants  of  a  village 
in  the  Punjaub  w^ere  turned  out  of  their  village  and  placed  in  camp 
because  of  a  commencing  mortality  among  rats.  While  in  camp  two 
women  were  permitted  to  visit  their  home  and  found  on  the  floor  of 
their  house  some  dead  rats ;  these  they  picked  up  and  threw  into  the 
street ;  they  returned  to  camp  and  a  few  days  later  they  were  attacked 
with  plague.  Two  instances  placed  before  the  Indian  Plague  Com- 
mission may  be  mentioned.  Both  were  villages  in  the  Punjaub  and 
under  the  supervision  of  Captain  James  of  the  Indian  Medical  Service. 

"  The  inhabitants  of  Mahlgahla,  some  2500  in  number,  were  placed 
in  camp  by  Captain  James,  I. M.S.,  on  account  of  an  outbreak  of  plague 
which  was  confined  to  one  special  quarter  of  the  village.  This  quarter 
having  been  disinfected  without  incident  the  disinfection  of  the  rest 
of  the  evacuated  village  w-as  taken  in  hand.  In  the  absence  of  other 
available  labour  the  house  owners  were  here  employed  upon  the 
disinfection  of  their  own  houses.  As  soon  as  they  were  set  to  work 
they  came  upon  dead  rats  all  over  the  village,  in  one  case  no  fewer 
than  15  of  these  being  found  in  a  single  room.     F'ive  days  after  the 


218  EpidemioliHui  of  Plague  [part  ii 

coinmencenient  of  the  work  of  disinfecting  the  houses,  which  had  been 
free  of  plague  at  the  time  the  vilhige  was  evacuated,  numerous  cases 
of  plague  began  to  occur  among  the  disinfectors.  So  severe  was  the 
outbreak  of  the  disease  among  these  (the  resulting  epidemic  did  not 
subside  till  75  persons  in  all  had  been  attacked)  that  the  disinfec- 
tion operations  had  to  be  suspended.  The  quarter  of  the  village 
in  which  most  of  the  disinfectors  were  attacked  was  the  quarter 
most  remote  fi'om  that  in  which  the  original  group  of  plague  cases 
had  occurred'." 

The  second  case  is  the  village  of  Chak  ]\alal,  which  was  evacuated 
as  a  precautionary  measure.  "  A  few  days  afterwards  owing  to  the 
downpour  of  rain  a  considerable  number  of  the  inhabitants  returned 
to  their  houses.  A  number  of  rats  (and  these  were  shown  by  bacterio- 
logical examination  to  have  died  of  plague)  were  found  lying  dead  all 
over  the  village.  Within  a  few  days  afterwards  quite  a  considerable 
number  of  people  contracted  plague.  It  seems  clear  that  the  infection 
was  here  disseminated  over  the  w  hole  village  as  a  result  of  the  outbreak 
of  plague  in  an  epidemic  form  among  rats"^." 

The  agency  by  w^hich  plague  is  transmitted  from  the  rat  to  man  is 

unfortunately  still  a  matter  of  conjecture.     Three  modes 
The  agency  .  "^  . 

by  which  have  been  suggested ;  one  is  by  the  parasites  on  the  rat, 

plague  IS  .^  second  is  by  food  which  has  been  contaminated  by  the 

transmitted  ■^  _  J 

from  the  rat  saliva,  excreta,  and  urine  of  plague-stricken  rats,  and  a 
third  is  by  inoculation  of  the  foot  or  hand  owing  to  an 
abrasion  coming  into  contact  with  bacilli  on  the  rat  itself  or  on  some- 
thing soiled  by  the  plague  rat.  It  will  only  be  necessary  to  deal  at  this 
stage  with  the  first,  as  the  others  wall  be  considered  when  treating  of 
the  channels  by  which  the  infection  enters  the  human  system.  Of  the 
The  flea  parasites  of  the  rat  the  flea  is  the  most  important,  firet 

theory.  because  it  is  a  blood -sucking  insect,  and  secondly  because 

it  possesses  the  power  of  transferring  itself  from  animal  to  animal.  Many 
observers,  the  first  being  Ogata^,  have  found  plague  bacilli  in  fleas  taken 
from  plague-infected  rats,  the  bacilli  remaining  in  the  bodies  of  the  fleas 
for  some  time  after  feeding  on  infected  blood.  The  fleas  themselves  are 
apparently  not  injuriously  affected  by  the  bacilli.  On  this  observation, 
coupled  with  the  fact  that  fleas  are  frequently  numerous  on  such  rats, 
Simonds  conceived  the  theory  that   the  flea  is  the  connecting  agent 

'  Report  Indian  Plague  Conunitmion,  Vol.  v.  chap.  iii.  p.  124. 

2  Ibid.  p.   1-25. 

^  "Ueber  die  Pestepidemie  ill  Formosa."    Centralhlatt  fi'ir  Bakteriologic,  Vol.  .\xi.  1897. 


CH.  XI]  The  Role  of  Titfected  Flem  219 

between  plague  in  man  and  the  rat.  When  the  rat  becomes  ill  it  is 
sometimes  covered  with  fleas,  which  leave  the  body  on  its  death  and 
transfer  themselves  to  other  animals.  It  is  in  this  transference  of  fleas 
from  an  infected  rat  to  a  healthy  one  or  to  man  that  Simonds  explains 
the  mode  of  dissemination  between  rat  and  rat  and  between  rat  and 
man.  Nuttall'  in  subjecting  these  views  to  the  experimental  test, 
including  both  bugs  and  fleas,  which  he  allowed  to  bite  animals  dying 
from  plague  and  then  inniiediately  afterwards  transferred  them  to 
healthy  animals,  was  unable  to  produce  a  single  case  of  infection. 

The  theory  of  Simonds  rests  on  the  view  that  plague  is  usually 
caused  both  in  man  and  in  the  rat  by  inoculation  of  the  infection 
through  the  skin,  and  on  the  aptitude  of  rat  fleas  for  biting  man.  Both 
of  these  have  been  controverted.  It  is  a  fascinating  theory,  but  it  still 
requires  much  more  evidence  in  its  support  than  exists  at  present  to 
place  it  on  an  absolutely  flirm  foundation,  and  even  then  it  by  no 
means  excludes  other  agencies. 

Four  species  of  fleas,  Typhlopsylla  rausculi,  Pulex  fasciatus,  Pulex 
serraticeps,  and  Pulex  pallidus,  have  been  found  on  rats,  while  two, 
Pulex  irritans  and  Pulex  serraticeps,  have  been  found  on  man.  The 
Pulex  serraticeps  is  also  commonly  found  on  dogs  and  cats.  There  can 
be  little  doubt  that  the  Pvdices  will  bite  man  if  they  have  the 
opportunity  though  it  may  be  only  on  occasion  that  they  do  so.  The 
fact  that  they  do  bite  man  has  been  observed  by  Tidswell"  and  by 
Gauthier^  and  Raybaud. 

The  only  experiments  hitherto  made  which  appear  to  support  the 
view  that  fleas  from  a  plague  rat  may  possibly  cause  plague  in  higher 
animals  are  those  mentioned  as  having  been  made  at  Hongkong.  They 
are,  however,  not  conclusive  in  that  the  results  obtained  were  solely 
clinical,  the  illness  from  which  the  monkeys  suffered  not  proving  fatal, 
and  no  examinations  having  been  made  to  ascertain  the  presence  or 
absence  of  plague  bacilli  in  the  organs  of  the  monkeys. 

On  the  other  hand,  the  transmission  of  plague  from  rat  to  rat  by 
the  agency  of  fleas  has  been  successfully  accomplished  by  MM.  J.  C. 
Gauthier  and  A.  Raybaud,  who  in  five  experiments  were  able  to  convey 

'  Nuttall,  "On  the  role  of  insects,  arachnids,  and  myriapods  as  carriers  in  the  spread 
of  bacterial  and  parasitic  diseases  of  men  and  animals."  Johns  Hopkins  Hospital  Ri ports, 
Vol.  VIII.  1900. 

-  Report  of  the  Board  of  Health  on  a  Second  Outbreak  of  Planue  at  Si/dney,  1902,  by 
J.  A.  Thompson,  M.D.,  D.P.H. 

*  Revue  d^Hjifiiene,  xxv.  p.  4'2t),  May,  1903. 


220  Epidemioloify  of  Plague  [part  ii 

the  disease  to  healthy  rats  by  the  bites  of  fieas  which  had  fed  on  a 
plague-infected  rat. 

Experiments  also  carried  out  in  Bombay  by  Dr  Elkington  and 
Captain  Liston  of  the  Indian  Medical  Service  were  successful  in  con- 
veying the  disease  by  Heas  from  infected  to  healthy  rats  and  from  a 
septicaemic  case  of  ])lague  in  man  to  healthy  rats^ 

An  interesting  obseivation  was  made  by  Dr  J.  M.  Clarke  in  regard 
to  the  immunity  of  a  locality  near  which  })lague  was  prevalent.  While 
plague  continued  at  Lpiique  not  a  single  case  of  plague  originated  in  the 
interior-  innuediately  adjoining,  which  was  on  the  Pampas  and  some  three 
thousand  feet  above  the  sea,  where  the  deposits  of  nitrate  of  soda  are 
found  together  with  immense  salt  beds,  although  there  was  a  continual 
interchange  of  population  whose  habits  were  filthy,  and  sanitary  measures 
unknown.  It  is  suggested  by  Dr  Clarke  that  the  immunity  might  have 
been  due  to  fleas  not  being  able  to  live  in  the  locality.  By  way  of 
experiment  a  number  of  fleas  were  taken  up  and  in  less  than  one  hour 
they  all  died. 

Rats  do  not  exhaust  the  list  of  rodents  or  other  animals  which  may 

disseminate  plague.  It  was  a  commonly  accepted  opinion 
lu  the  16th  ,      1 .    ,  1  -,  K  1  •         1  ,  •  , 

and  17th  m  the  loth  and  uth  centuries  that  cats,  dogs,  pigeons  and 

centuries  fowls  spread   the  disease.     Athanasius  Kircher,  after  de- 

cats,  dogs,  J^  ' 

pigeons  and  scribing  the  manner  in  which  the  contagious  virus  adheres 
believed  to  ^'*  bedding,  linen,  clothes,  skins,  carpets,  leather,  even  to 
spread  spoons,  knives,  tabletops,  cups,  shoes,  belts,  &c.,  adds  that 

animals  such  as  "  cats,  dogs,  pigeons,  fowls  and  the  like, 
dwelling  within  the  precincts  of  an  infected  house  at  the  very  first 
contact  with  the  things  infected  take  the  contagiousness  which  breeds 
contagion ;  and  even  if,  by  a  kind  of  contrariety  of  nature,  they  are  not 
affected  internally  by  it  they  nevertheless  do  carry  it  into  the  neigh- 
bouring houses  and  spread  the  plague  they  have  caught  throughout  the 
city.  Therefore,  in  time  of  plague,  the  slaying  and  extermination  of 
dogs  and  cats  and  suchlike  domestic  animals  is  ])rescribed.  Examples 
beyond  all  count  show  how  great  is  the  danger  from  such  animals  when 
a  house  is  stricken  by  plague^"  He  quotes  the  case  of  a  nun  in  Milan 
who,  w^hen  the  plague  was  lieginning  in  that  city,  isolated  herself  from 
her  companions  and  endeavouivd  to  protect  herself  by  fumigating  and 
burning  of  .scents  in  hor  chamber.     On  one  occasion,  however,  having 

1  Aiistnilasiau  Medical  Gazette,  xxii.  p.  .348,  August,  11)03. 

2  Athanasii  Kircheri,   E.   S.   J.,   Scnttiniuni  I'lnjuico-Mi'dicinii  C<)nta<jiosae   I-tiis,  quae 
Pestis  dicitur.     Home,  1G58. 


cii.  xi]         Older  Views  regarding  Dissemination  221 

to  leave  her  cell,  the  door  was  left  open  and  on  her  return  she  found  a 
cat  on  the  bed  that  had  caught  the  plague  elsewhere,  which  is  believed 
to  have  infected  the  bed,  which  again  infected  the  nun,  who  was  attacked 
and  died  on  the  third  day  of  her  illness.  It  is  remarked  by  Orengius,  on 
whose  authority  the  story  is  given,  that  the  cats  on  the  premises  were 
killed  and  the  nunnery  after  that  was  free  from  the  contagion. 

There  are  few  old  "  plague  orders  "  that  do  not  attach  importance  to 
the  destruction  of  dogs  and  cats.  Dr  Maunagetta  in  his  "plague  order" 
mentions  that  Dr  Marsilius  Ficinus,  who  reports  on  the  plague  of  1479 
in  Florence,  states  that  plague  was  conveyed  from  infected  houses  to 
healthy  ones  by  cats  and  dogs.  Roderick  von  Casto  made  a  similar 
observation  during  one  of  the  plagues  of  Hamburg. 

At  Padua  during  an  epidemic  all  the  dogs  and  cats  within  a  radius 
of  4  miles  were  destroyed  in  order  to  prevent  the  extension  of  the 
plague.  In  the  London  epidemic  of  1543'  the  plague  order  enjoins 
among  other  things  "  that  all  persons  having  any  dogs  in  their  house, 
other  than  hounds,  spaniels,  or  mastiffs,  necessary  for  the  custody  or  safe 
keeping  of  their  houses,  should  forthwith  convey  them  out  of  the  citv  or 
cause  them  to  be  killed  and  carried  out  of  the  city  and  burned  at  the 
common  lay-stall,  and  that  such  as  kept  hounds,  spaniels,  or  mastiffs 
should  not  suffer  them  to  go  abroad  but  closely  confine  them." 

In  subsequent  orders  similar  injunctions  in  regard  to  dogs,  cats,  and 
swine  appear.  At  the  height  of  the  Marseilles  epidemic  it  is  recorded 
that  no  fewer  than  10,000  dogs  had  been  killed.  Skeyne  in  1568  remarks 
that  if  the  domestic  fowls  become  pestilential  it  is  the  sign  of  a  most 
dangerous  pest  to  follow.  The  Franks  in  Egypt  and  Syria,  when 
shutting  themselves  up  in  their  houses  during  the  plague  season,  which 
used  to  be  their  custom,  also  shut  up  in  cages  their  dogs  and  cats,  and 
were  careful  to  shut  up  all  openings  or  holes  to  prevent  any  animal 
gaining  access  to  the  house  from  the  outside.  Any  animal  entering  the 
house  was  immediately  killed. 

It  was,  moreover,  held  that  insects  were  the  means  of  conveying 
Ancient  beUef     contagion.     Dr  Girolamo  Mercurialis  in  the  16th  century 

in  the  possi-       states  that  flies  filled  with  the  iuice  from  patients  as  well 

bility  of  in-  .  .  i  •    ,  ,  •  , 

sects  convey-      i'ls    corpses    passmg    into   the   neighbourmg   houses   and 

ing  infection,  tainting  with  their  dirt,  eatables,  have  brought  the  con- 
tagion upon  such  people  as  partook  of  them.  Athanasius  Kircher 
instances  a  case  of  infection  caused  by  a  hornet :  "  In  the  late  plague  of 

^  History  of  Epidemiol  in  Britain,  Vol.  i.  p.  314.     By  Cbailes  Creigbton,  M.A.,  M.U., 
1891. 


222  Epldemiolocfy  of  Plague  [part  ii 

Naples  a    nobleman   was  looking  at    something  at  the   window   when 

suddenly  a  hornet  tlew  in  and  settled  upon  his  nose  and  stinging  him 

produced   a    swelling :    gradually    this  grew    and    the  poison   creeping 

through  his  flesh  within  two  days  of  catching  the  plague  he  died,  most 

certainly  from  the  contagious  humour  which  the  insect  had  sucked  from 

a  corpse." 

From  observations  then  made,  when  plague  used  to  be  prevalent  in 

Europe  and  Egypt,  it  is  evident  the  opinion  was  formed  that  animals 

and  insects  were  able  to  spread  the  infection.     That  opinion  has  been 

confirmed   in    many  respects  by   the  experiments  and   observations  of 

recent  years.     It  has  already  been  shown  that  fleas  may  be  transmitters 

of  plague  infection  from  rat  to  rat.     Ants,  bugs,  flies  and  mosquitoes 

have  also  at  various  times  come  under  suspicion  of  being  either  active 

or  passive  agents  in  the  dissemination  of  plaefue.     Plague 
Plague  bacilli  .  i      o  o 

detected  in         bacilli   have   been  detected  in  ants,  bugs  and  flies  which 

and^kf^^^  have  fed  on  or  come  into  contact  with  plague  material  in 

an  infected  house,  or  in  a  mortuary,  or  in  the  laboratory. 

An  interesting  case  is  reported  by  Calmette  and  Salimbeni  in  the 

Oporto  epidemic  of  1899  in  which  the  lesion  produced  by  the  bite  of  a 

bug   was   the  starting-point   of   an   infection   of  plague'.     The    person 

attacked  was  bitten  on  the  night  of  Sept.  21st  by  a  bug  on  the   left 

hand ;  the  next  day  the  hand  and  forearm  were  in  a  state  of  intense 

inflammatory  oedema  and  at  the  site  of  the  bite  a  large  black  areola 

formed,  the  centre  quickly  necrosing  and  the  necrosis  extending  soon 

over  the  whole   of  the  doi^sum   of   the  hand.     On  the   same   day  the 

symptoms  of  plague  declared  themselves.     On  the  23rd  September  the 

temperature  was  40°  C. ;  there  was  delirium ;  the  cervical  glands  were 

much  engorged  and  painful,  especially  the  right ;  the  inguinal  glands  on 

both  sides  were  slightly  swollen  and  sensitive  to  pressure;  a  track  of 

lymphangitis  on  right  thigh  and  ecchymosis  on  the  back  of  the  right 

hand.    On  the  24th  September  the  temperature  was  38-5^  C,  pulse  120, 

tongue  and  lips  fuliginous,  respiration  frequent  and  the  patient  sank  into 

a  state  of  coma  which  continued  for  three  days,  death  occurring  on  the 

27th  September.     The  post-mortem  of  this  case  showed  large  necrotic 

ulceration  on  the  dorsum  of  the  left  hand,  a  right  femoro-inguinal  bubo, 

which    when    incised   exuded    a   dense    and    viscous  chocolate-coloured 

fluid;    general    glandular   enlargement  and   the   usual   appearances    of 

a  septicaemia. 

'   "La  Peate  Bubonique,  etude  ile  repiiiemie  d'Oporto  en   1899."     I'ar  A.  Calmette  et 
A.  T.  Salimbeui,  Aimules  de  I'lnslilut  Fasteur,  December,  1899. 


CH.  xi]  The  Tarbafian  and  Plague  223 

It  is  established  experimentally  that  animals  of  different  species  are 
The  r6ie  of         more  or  less  susceptible  to  plague ;  among  these  are  cats, 

animals  other     dogs,  pigs,  calves,  sheep,  poultry,  monkeys,  and  squirrels 

than  rats  in  ,  ,  y^,  ^  i       ^  ^•  i 

the  dissemi-       '^^ncl  snakes,     rlague  has  also  been  discovered  as  occurring 

nation  of  ^y  natural   infection  among  cats  in  the  Mauritius,   Cape 

plague  not  "^  °  .  ,  '         r 

judged  to  be       Town  and  elsewhere,  among  dogs  in  China,  among  poultry 

from^existing      ^^^  Hongkong,  among  monkeys,  squirrels  and  porcupines  in 

observa-  India,  and  in  a  wallaroo,  pademelon,  tree-kangaroo,  Indian 

antelope  and  wallabies  in  Sydney.    There  is  reason,  also,  to 

suspect   the   susceptibility  of  moles  and   bats.     The  role   of   all   these 

animals  in  the  direct  dissemination  of  plague  in  the  existing  pandemic 

has  not  yet  been  proved  to  be  of  much  importance.     Possibly,  as  plague 

becomes  more  diffused  and  endemic  in  the  areas  that  it  has  invaded,  the 

natural  infection  to  which  these  animals  are  subject  may  have  a  greater 

opportunity  of  becoming  more  general,  and  the  older  observations  as  to 

their  power  of  disseminating  the  infection  will  be  found  to  be  correct. 

In  regard  to  direct  infection  communicated  by  the  cat  an  interesting 
case  occurred  in  the  Cape  Town  outbreak  of  1901.  The  Rev.  Mr  Gress- 
ley,  who  took  up  his  residence  in  the  Health  Camp  and  voluntarily 
performed  the  duties  of  chaplain,  was  attacked  with  plague  under  the 
following  circumstances :  a  cat  of  his  became  sick  and  after  a  few  days 
died  ;  examination  proved  its  illness  and  death  to  be  due  to  plague. 
One  peculiarity  of  the  bacillus,  however,  was  its  staining  with  Gram's 
method.  A  few  days  afterwards  Mr  Gressley  was  attacked  with  plague, 
his  infection  being  attributed  to  the  cat.  Curiously  enough  the  bacillus 
in  Mr  Gressley 's  bubo  also  possessed  the  character  of  staining  with 
Gram's  method. 

The  epizootic  disease  which  affects  the  tarbagan  marmot,  a  rodent 

„^    ,    .^  which    is    very   common   in    the   Transbaikal   province  of 

The  tarbagan  .  '^  '■ 

(Arctomys  bo-  Siberia,  has  already  been  stated  to  be  communicable  to 
toanepi-°*  '"'"^-  Although  the  bacteriological  test  has  not  been 
zootic  much  applied  yet  the  descriptions  given  by  Dr  Bieliavski  and 
l)r  Rieshetnikof  respectively  leave  little  doubt  that  the 
disease  affecting  these  rodents,  and  which  is  liable  to  be  communicated 
to  man,  is  ])lague. 

Dr  Clemow  gives  in  the  Journal  of  Tropical  Medicine^  a  full  and 
interesting  account  of  the  disease,  derived  from  the  contents  of  two 
articles  published  in  the  Joumal  of  General  Hygiene  and  Legal  ami 

'  "Plague  ill  Siberia  and  Mongolia  and  the  Tarbagan  (Arctomys  bobac)."  By  Frank 
Clemow,  M.D.,  D.P.H.,  Journal  of  Tropical  Medicine,  February,  1900. 


224  Epklenuolofiji  of  Plague  [paut  ii 

Practical  Medicine  for  A])ril,  1895  {Viestnik  obshtchestvennoi  Gigienui 
Sudehwi  i  Praktitcheskoi  Meditzinui),  the  official  journal  of  the  medical 
department  of  the  Russian  Ministry  of  the  Interior. 

The  tarbagan  is  a  rodent  of  about  26  inches  in  length,  with  a  thick 
fur  of  a  dull  yellow  colour,  which  is  of  a  darker  shading  on  the  back  and 
snout  and  round  the  lips  and  eyes.  The  animal  builds  large  under- 
ground dwellings  in  which  it  hybernates  from  Sepfcember  to  ]\Iarch.  It 
is  hunted  b}-  the  nomad  Buriats  and  by  the  Cossacks,  its  flesh  being 
considered  a  delicacy  for  the  table,  but  it  is  principally  sought  for 
on  account  of  its  fat,  which  is  used  for  greasing  straps,  harness  and  other 
leather  objects.  In  some  years,  and  usuall}^  in  the  autumn,  the  tarbagan 
is  attacked  by  an  epizootic  disease,  the  symptoms  of  which  are  as 
follows. 

The  animal  becomes  languid  and  ceases  to  bark  ;  its  gait  is  unsteady 
and  sometimes  under  one  shoulder  a  reddish  tense  swelling  appears ;  if 
far  from  its  home  the  animal  may  be  unable  from  its  dazed  condition  to 
find  it,  and  readily  falls  a  prey  to  its  foes.  Sometimes  the  swelling  is 
absent  or  very  small,  and  the  Buriats,  to  determine  whether  the  animal 
is  diseased  or  not  cut  into  the  sole  of  one  pad  and  if  the  blood  is 
coagidated  they  consider  the  animal  is  diseased  and  give  it  to  the  dogs. 
Dr  Clemow  remark.^-  that  it  is  an  interesting  fact  that  neither  dogs  nor 
wolves  contract  the  disease. 

The  disease  in  man  which  is  believed  to  be  contracted  from  this 
The  disease        epizootic  disease  of  the  tarbagan  has  the  clinical  symptoms 

in  man  con-       ,)f  i)lague  with  its  gi'eat  fatality.    The  symptoms  are  severe 

tracted  from  i      o  o  .,  ^       jr 

sick  tarba-        headache,  fever,  vomiting,  sometimes  diarrhoea,  but  more 

^^°^  commonly  constipation,  and  pain  in  the  arm-pit  or  groin 

with  glandular  swelling,  which,  however,  is  not  always  present,  ending 

fatally  as  a  rule  in  a  few  days.     In  the  village  of  Soktui  in  August, 

1889,  in  a  Cossack  family  of  ten  persons  a  girl  aged  16  years  died  of 

this  disease  after  three  days'  illness,  and  her  death  was  followed  by  that 

of  three  other  members  of  the  fiimily.     Then  a  relative  took  home  some 

of  the  clothes  and  washed  thi'ui,  and  in  a  few  days  was  attacked  with  the 

disease  and    died.     Five   other  members    of  this    second    family  were 

attacked  and  died  and  only  a  child  of  five  years  remained  unaffected;  a 

young  Buriat  aged  10  years,  who  played  with  the  children,  also  sickened 

and  died. 

It  appears    that   the   membei-s    of  the    family  first  attacked   were 

occupied  in  catching  and  skinning  tarbagans,  and  two  years  later  one  of 

the  remaining  .six  sons  contracted  the  disease  and  died  after  skinning 


CH.  xi]  The  Tarhagan  Disease  225 

and  removing  the  fat  from  a  sickly  looking  animal.  His  death  was 
followed  by  that  of  his  brother,  aged  5.  At  the  same  time  in  the  town 
of  Aksha  a  small  outbreak  took  place,  the  first  case  being  that  of  a  man 
who,  while  away  from  home,  had  eaten  some  tarbagan  flesh  with  some 
Mongolians.  He  sickened  the  day  after  his  return  and  died  three  days 
afterwards.  Five  other  members  of  the  family  were  attacked  and  died. 
One  of  these  was  removed  while  ill  to  a  neighbour's  house,  where  two  of 
the  household  afterwards  sickened  and  died.  The  symptoms  were  high 
fever,  giddiness,  severe  headache,  red  and  flushed  face  with  anxious 
expression,  rapid  and  progressively  weaker  pulse.  Some  patients  com- 
plained of  oppression  and  pain  in  the  chest  with  occasional  dry  cough, 
and  the  expectoration  of  a  small  amount  of  occasionally  blood-stained 
sputum.  The  weakness  and  depression  were  extreme,  but  there  was 
usually  consciousness  to  the  end.  In  some  there  was  pain  and  swelling 
of  the  glands  in  the  axilla  or  groin,  while  in  others  there  were  no 
glandular  swellings. 

In  1894  there  was  a  severe  visitation  in  Soktui  in  another  Cossack 
family,  which  was  caused  by  the  head  of  the  family,  on  his  way  to  attend 
the  court  at  Tzagan-Olui,  carrying  six  tarbagans  which  his  dog  had 
caught  and  killed.  The  rapidity  with  which  the  animals  were  caught 
seemed  to  show  that  they  must  have  been  suffering  from  disease.  He 
was  taken  ill  two  days  after  his  return  home  and  died  three  days  later. 
His  symptoms  were  headache,  drowsiness,  vomiting  and  diarrhoea.  On 
September  14th  the  youngest  son  fell  ill  with  the  same  symptoms,  and 
had  pain  and  swelling  "  in  the  arm-pits  and  groins."  On  September 
15th  a  son,  on  the  17th  the  mother,  on  the  19th  the  grandfather, 
on  the  29th  the  grandmother,  on  the  23rd  the  eldest  daughter  fell  ill 
and  died. 

None  of  the  villagers  would  go  near  the  sick  but  they  brought  food 
and  drink  for  them,  which  they  placed  at  some  distance  from  the  infected 
house.  The  dead  were  buried  by  the  survivors,  who  threw  into  the 
grave  the  clothes  and  linen  of  the  deceased.  Sixteen  days  after  the  last 
death  the  survivors  went  to  the  house  of  a  relative  after  changing  all 
their  clothes  in  an  out-house,  burning  their  old  clothes  and  putting 
on  new  ones  provided  by  the  relative. 

The  tarbagan  is  to  be  found  in  Eastern  Europe,  Siberia,  Mongolia, 
and  Tibet,  but,  as  pointed  out  by  Dr  Clemow,  there  is  no  evidence  to 
show  that  it  suffers  from  the  fatal  epizootic  described  except  in  the 
Transbaikal  province,  and  possibly  in  the  neighbourhood  of  the  Solenko 
valley  in  Mongolia, 

s.  15 


PART   III. 

PLAGUE   IN   THE     INDIVIDUAL. 


CHAPTER  XII. 

MORBID  ANATOMY  AND  PATHOLOGY. 

It  is  usually  on  the  post-mortem  table  that  the  first  case  of  plague  is 
discovered.  The  characteristic  appearance  in  a  necropsy  of  plague  is 
that  of  engorgement  and  haemorrhage  associated  witli  enlargement 
of  the  lymphatic  glands  and  extravasations  into  the  periglandular 
tissues  of  one  or  more  groups  of  these  glands.  Nearly  every  organ 
participates  more  or  less  in  the  extravasation  of  blood  from  the  veins. 

Professor  Frazer'  (now  Sir  Thomas)  points  out  that  the  vascular 
changes,  and  especially  the  pervading  and  characteristic  tendency  to 
extravasation  of  blood  in  almost  every  part  of  the  body,  are  closely 
reproduced  in  the  toxaemia  caused  by  the  organic  poison  secreted  by  the 
venom  glands  of  several  species  of  serpents,  such  as  the  black  snake 
(Pseudechis  porphyriacus)  of  Australia. 

Pathological  changes  special  to  plague  occur  in  the  skin,  lymphatic 
glands  and  the  adjoining  blood  vessels,  in  the  spleen,  lungs, 
heart,  liver,  and  kidneys.  Decomposition  of  the  dead 
body  is  ncjt  accelerated  in  plague  unless  in  thi;  mixed  form  when  strepto- 
cocci are  present,  then  putrefaction  may  set  in  very  early.  On  the  skin 
there  are  often  small  haemorrhages  chiefly  on  and  in  the  vicinity  of  the 
bubo  and  on  the  head,  arms,  neck  and  shoulders ;  these  haemorrhages 
contain  plague  bacilli.  Haemorrhages  are  also  found  in  the  muscles, 
chiefly  in  those  of  the  abdomen  and  of  the  temporal  bones,  as  well  as  in 

'  Report  of  the  Indian  Plague  Commission,  Vol.  v.  Appendix  ii.  p.  436. 


CH.  xii]  Morbid  Anatomy  and  Pathology  227 

the  muscles  near  the  primary  bubo ;  they  contain  polynuclear  leucocytes 
and  plague  bacilli.  Carbuncles,  boils,  vesicles,  or  pustules  may  be 
present  on  any  part  of  the  body.  Epidemics  differ  much  in  this  respect, 
some  being  distinguished  for  the  comparative  rarity  of  these  skin 
manifestations,  others  for  their  frequency.  They  appear  over  intensely 
inflamed  glands  or  in  other  regions  of  the  body,  and  are  local  infiltrations 
of  the  skin  and  areolar  tissue  and  contain  plague  bacilli  and  leucocytes. 
They  vary  in  size,  present  at  first  a  vesicular  or  blister-like  appearance 
on  the  surface  of  the  skin,  but  when  the  blister  is  broken  there  is  under- 
neath an  ulcer  with  uneven  surface  of  a  reddish-yellow  colour.  Cut 
into,  they  are  thick,  hard  and  dense  and  haemorrhagic. 

The  condition  of  the  lymph  glands  is  peculiar  to  plague.  There  is 
Lymphatic  ^^  other  infectious  disease  which  shows  a  similar  multiple 
glands.  inflammation    of    the    lymphatic    glands,    together   with 

haemorrhages,  exudative  infiltrations  into  the  periglandular  tissue,  and 
presence  of  characteristic  bacilli. 

In  the  bubonic  form  the  gland  or  group  of  glands  affected  are 
manifested  externally  as  buboes  in  the  region  of  the  groin, 
primary  arm-pit,  and  neck.     The  groin  is  by  far  the  most  fi-equent 

'^  °^^'  site,  one    or    both  sides  exhibiting  buboes.     Occasionally 

there  are  buboes  at  the  elbow  and  in  the  space  behind  the  knee.  The 
buboes  vary  in  size  and  shape  according  to  their  situation,  the  number 
of  glands  affected,  and  the  amount  of  haemorrhagic  serous  or  sero- 
sanguinolent  effusion  from  the  glands  into  the  periglandular  tissue.  At 
times  the  amount  of  effusion  is  small  or  absent,  and  only  one  or  a  few 
glands  slightly  swollen,  then  the  bubo  is  small  and  easily  felt.  Most 
frequently  the  opposite  conditions  prevail.  The  effusion  is  extensive, 
the  bubo  is  large  and  readily  recognised.  Then  the  connective  tissue  is 
infiltrated  with  blood  or  with  a  yellow  gelatinous  oedema,  or  with  both, 
which  mats  together  the  haemorrhagic  and  much  swollen  glands  and 
forms  a  swelling  which  may  be  the  size  of  a  man's  fist.  The  exact 
limits  of  this  tumour  are  often  ill-defined  owing  to  a  surrounding 
oedematous  condition.  Between  the  above-mentioned  extremes  there  is 
every  gradation.  Anatomically  then  the  bubo  consists  of  connective 
tissue  more  or  less  engorged  or  infiltrated  with  blood,  or  serum,  or  both, 
which  forms  a  dense  sanguineous  gelatinous  or  oedematous  mass  in 
a  state  of  inflammation  in  which  is  embedded  one  or  more  enlarged 
glands  inflamed  or  haemorrhagically  infarcted.  On  the  boundaries  of 
this  hard  and  tense  tumour  there  is  often  an  extensive  oedema.  The 
colour  of  the  bubo  and  the  adjacent  tissues  will  accord  with  the  relative 

15—2 


228  Plague  in  the  Indiviiliial  [part  m 

amount  of  blood  or  exudative  infiltration  et!"used  from  the  glands,  the 
one  being  black  and  the  other  yellow.  Much  variety  in  coloration  will 
occur  according  to  whichever  predominates.  The  mass  will  also  exhibit 
different  stages  of  inflammation,  exudation,  haemorrhagic  infarction, 
suppuration  and  necrosis  according  to  the  intensity  of  the  disease  and 
the  (hiratinn  of  the  illness.  The  size  of  the  separate  swollen  glands 
varies,  being  from  that  of  a  pea  to  that  of  a  walnut.  The  enlargement 
is  due  to  hyperaemia,  inflammation,  exudation  and  haemorrhage,  and 
these  processes  obliterate  more  or  less  the  distinction  between  cortical 
and  medullary  substance.  The  condition  of  the  lymphatic  glands 
depends  largely  on  the  time  of  death.  In  severe  cases  in  which  death 
takes  place  rapidly  the  glands  may  be  of  a  purple  or  dark  plum  colour, 
and  partially  or  completely  infarcted  haemorrhagically  and  exhibit  on 
section  a  deep  red-brown  or  blackish-red  appearance.  The  haemorrhages 
with  an  exudative  oedema  may  have  broken  through  the  capsules  and 
infiltrated  the  surrounding  periglandular  tissue,  matting  together  the 
separate  glands  which  are  in  various  stages  of  inflammation,  and 
involving  the  neighbouring  fascia,  adipose  tissue,  muscles,  vessels  and 
nerve  sheaths  to  a  greater  or  less  extent.  In  other  cases  the  glands  are 
red  or  violet  or  brownish-red  in  colour,  moderately  hard  and  with  their 
capsules  distended.  On  section  the  parenchyma  may  be  of  soft  or  firm 
consistence  and  of  a  granular  mottled  or  marbled  appearance,  the  me- 
dullary substance  being  profusely  sprinkled  or  streaked  with  bright  red 
extravasations  of  varying  sizes.  At  the  periphery  of  the  gland  there  is 
frequently  a  fine  granulation  formed  of  yelloAv  nodules,  on  which  there  is 
a  ropy  or  viscid  material.  The  exudation  is  not  so  haemorrhagic  but  of 
a  sero-sanguinolent  nature  forming  a  yellow,  gelatinous  oedema  mixed 
with  blood  extravasations.  Commencing  necrosis  is  evidenced  by  a 
greyish-yellow  or  mottled  brownish-red  and  grey  appearance.  In  later 
cases  in  which  the  disease  is  protracted  to  the  8th  or  9th  day,  the 
parenchyma  of  the  gland  usually  contains  a  yellow  or  yellowish-red  pus, 
while  the  periglandular  tissue  may  have  improved  in  condition  or  is  in 
a  state  of  suppuration.  In  other  cases  there  may  be  a  general  sloughing 
of  glands  and  tissues. 

The  veins  in  the  vicinity  of  the  bubo,  such  as  the  femoral,  axillary 

and  jugular,  participate  more  or  less  in  the  disease,  beinsf 
Veins  in  the  i     ,7    ,  •  „  ,     •  •    • 

vicinity  of  emDeauea  in  a  yellow  gelatinous  mass  containing  extra va- 

^ff^  Td°  sated  blood.     They  are  affected  by  the  haemorrhagic  in- 

filtration  and  inflammatory   exudations   proceeding   from 
the  glands,  and  are  thus  often  incorporated  in  the  bubo  mass  forming 


CH.  XTi]  Morbid  AncUomy  and  Pathology  229 

a  part  of  the  tumour.  The  haemorrhages  and  inflammatory  exudations 
do  not  confine  themselves  to  an  infiltration  of  the  tissues  around  the 
veins,  but  they  penetrate  into  and  between  their  walls  so  that  when  the 
veins  are  opened  their  inner  surface  shows  large  and  suffused  hae- 
moiThagic  patches  which  become  smaller,  more  isolated  and  punctated 
the  further  away  they  are  from  the  bubo.  By  the  haemorrhages  into 
the  walls  of  the  veins  there  is  established  a  direct  communication 
between  the  glands  and  the  veins. 

Major  Childe,  I. M.S.,  was  the  first  to  point  out  this  haemorrhage  into 
the  walls  of  the  veins  included  in  the  bubo  and  the  continuity  of  the 
extravasated  blood  in  the  gland,  in  the  areolar  tissue  outside  the  gland 
and  in  the  walls  of  the  veins  incorporated  in  the  bubo'. 

This  destruction  of  the  walls  of  blood  vessels,  inside  and  outside  the 
glands  leading  to  haemorrhages,  appears  chiefly  to  be  brought  about  by 
the  plague  bacillus  and  its  toxines  in  the  glands  and  in  the  exudative 
infiltration  acting  chemically  on  the  minute  vessels  of  the  walls. 

There  may  be  other  buboes  in  connection  with  the  buboes  in  the 
Internal  groin,  arm-pit,  and  neck.     A  bubo  in  the  groin  not  infi-e- 

buboes.  quently  extends  through  the  crural  ring  into  the  pelvis  and 

abdominal  cavity,  involving  successively  the  glands,  tissues,  and  vessels 
in  the  iliac  and  lumbar  regions  and  forming  one  or  more  large  tumours. 
The  bubo  possesses  similar  characters  to  the  ordinary  bubo,  both  as 
regards  the  degree  of  intensity  and  number  of  glands  affected  and  as 
regards  the  amount  of  sero-sanguinolent  infiltration  and  oedema  into 
the  tissues  around  them  ;  occasionally  the  iliac  glands  show  much  more 
change  and  swelling  than  the  inguinal.  In  some  cases  the  chain  of 
glands  along  the  spinal  c(jlumn  as  far  as  the  thoracic  cavity  and  even  up 
to  the  hinder  mediastinal  glands  are  extensively  affected,  or  this 
condition  may  extend  over  to  the  glands  of  the  other  side  of  the  body 
and  thei'e  may  be  large  buboes  on  both  sides  of  the  spine  to  the 
diaphragm.  Similarly  in  an  axillary  bubo  the  chain  of  glands  to  the 
subclavian  vein  and  to  the  neck  may  participate,  while  a  bubo  in  the 
cervical  region  may  extend  down  into  the  thoracic  wall  and  affect  the 
glands  there  and  frequently  to  the  axilla.  These  internal  buboes  like 
the  external  are  characterised  by  altered  and  swollen  glands,  haemon-hages 
and  oedema,  and  may  be  in  a  worse  condition  than  the  external  ones, 
but  the  area  involved  and  the  acute  inflammatory  changes  in  the 
surrounding  tissues  are  usually  less,  there  being  more  of  the  yellowish 
gelatinous  oedema  than  there  is  of  the  copious  haemorrhagic  infiltration 
characteristic  of  those  buboes  first  affected.  The  glands  may  vary  from 
1  Report  of  Major  Lyons,  I.M.S.,  President,  Bombay  Plague  Research  Committee. 


230  Plarjnc  in  the  Individual  [part  iii 

the  size  of  a  pea  to  an  olive,  and  on  section  display  a  considerable  range 
in  the  degi-ee  to  which  they  are  affected,  some  being  completely 
haemorrhagically  infarcted,  while  others  are  of  a  reddish-brown,  reddish- 
yellow,  or  straw-yellow  colour.  Of  internal  glands  the  mesenteric  and 
retroperitoneal  are  frequently  affected.  This  was  very  noticeable  in  the 
autopsies  at  Hongkong.  They  were  generally  dark  red  or  purple  in 
colour,  of  the  size  of  a  bean,  and  embedded  in  an  extravasated  mass  of 
blood.  The  adjoining  veins  and  lymph  vessels  were  in  these  cases 
dilated  and  their  walls  suffused  with  blood. 

There  are  other  buboes  which  in  contradistinction  to  those  already 
Secondary  referred  to  may  be  termed  secondary^  although  they  may 

buboes.  not  be  preceded  by  primary  buboes.     They  originate  when 

the  circulation  is  invaded  in  force  by  the  plague  bacilli,  which  are  then 
carried  by  the  blood  to  different  glands  in  the  body.  This  occurs  either 
in  consequence  of  the  walls  of  the  veins  incorporated  in  the  bubo  be- 
coming so  damaged  by  the  infiltration  as  to  permit  of  a  direct  entrance 
for  the  microbes  from  the  glands  into  the  circulation,  or  it  occurs  in 
cases  when  the  blood  stream  is  directly  infected  and  the  bacilli  mul- 
tiply in  the  blood  instead  of  in  the  lymphatic  glands.  In  each 
instance  the  disease  becomes  septicaemic,  that  is,  the  blood  stream 
becomes  the  agent  for  the  distribution  of  the  plague  bacilli  to  the 
different  organs  and  glands  in  the  body.  These  secondary  buboes 
may  therefore  develop  in  all  regions  of  the  body  quite  independently  of 
the  seat  of  a  primary  bubo,  from  which  they  differ  in  some  very  important 
respects.  The  glands  are  enlarged,  but  seldom  larger  than  a  bean  or 
hazel-nut ;  they  are  hard  and  solid  and  of  a  pink  colour ;  on  section  they 
are  found  to  be  engorged  with  blood ;  and  the  parenchyma  is  hyperaemic, 
soft,  of  splenic  consistence  and  easily  scraped  off  with  a  knife.  In  a 
later  stage  the  soft,  swollen,  parenchymatous  tissue  is  oedematous,  with 
distinct  greyish-red  haemorrhages  and  softened  areas :  in  still  later  cases 
the  haemorrhagic  infarcts  occupy  a  considerable  area  within  the  gland, 
but  do  not  go  beyond  the  capsule,  so  that  further  than  occasional 
oedematous  condition  of  the  surrounding  tissues  there  is  rarely  any 
haemorrhagic  or  gelatinous  infiltration  to  be  seen  connected  with  these 
glands. 

The  best  description  of  the  histological  changes  is  given  by 
Albrecht  and  Ghon^  whose  work  in  Bombay  in  this  respect  on  behalf  of 
the  Austrian  Government  is  of  the  most  careful  and  minute  character. 

'  "Ueber  die  Beulenpest  in  Bombay  im  .Jahre  1897."  Gesammtbericht  der  von  der 
Kaiserlichen  Akndnuie  der  Wisseugchaft  in  Wien  znm  Studium  der  Beulenpest  nach  Indien 
entsendeter  Connni.ision.     Vienna,  18'.)8. 


CH.  xii]  Morbid  Anatomy  and  Patlwlogy  231 

Thi'   histological  changes  in  the  bubo  are  essentially  those   which 

are  produced  by  the  irritating  and  destructive  action  of 

changes  in         the  plague  bacillus  and  its  toxines.     They  appear  to  be 

primary  gj,g^  qx\  inflammatory  action  on  the  cellular  elements  of  the 

bubo.  .  .... 

tissues,  followed  by  necrotic  and  disintegrating  processes 

which  affect  the  capillaries  and  blood  vessels,  leading  to  haeinorrhages 
and  exudative  infiltrations  which  favour  a  further  destructive  effect  and 
a  further  spread  of  the  bacillus.  Wherever  bacilli  are  to  be  found  in 
large  numbers,  which  is  the  case  in  a  primary  bubo,  there,  sooner  or 
later,  the  tissues  gradually  break  up,  disintegrate,  and  finally  form  into 
masses  of  detritus.  With  the  gland  as  the  starting-point  of  the  tissue 
changes  in  the  bubo,  the  glandular  tissue  shows  a  more  advanced  degree 
of  haemorrhages,  infiltration  of  leucocytes  and  bacilli  and  necrotic  de- 
generations than  the  periglandular  tissue. 

With  the  invasion  of  the  bacilli,  which  may  be  aggregated  in  masses 
in  the  gland  or  extend  throughout  the  whole  gland,  the  parenchyma  is 
either  partially  or  completely  disintegrated.  Haemorrhagic  extravasations 
take  the  place  of  the  disintegrated  portion  of  the  gland,  or  it  is  crowded 
with  polynuclear  leucocytes  showing  a  tendency  to  necrosis.  There  is 
also  a  very  abundant  infiltration  of  plague  bacilli.  The  appearance  is 
variable,  depending  on  the  amount  of  the  haemorrhages,  the  infiltration 
of  leucocytes  and  bacilli  and  the  necrosis.  With  the  complete  or  almost 
complete  disintegration  of  the  adenoid  tissue,  the  normal  structure  of 
the  gland  disappears  and  the  separate  parts  are  indistinguishable.  The 
leucocytes  are  in  such  masses  that  they  give  the  appearance  of  a 
purulent  infiltration.  In  the  infiltration  itself  there  is  a  granular 
disintegration  of  the  nuclei  as  well  as  of  the  leucocytes,  the  detritus 
extending  over  large  areas,  or  the  outline  of  the  cells  may  be  more  or 
less  retained,  but  the  nuclei  have  disappeared  or  are  indistinct.  The 
necrosis  is  generally  most  marked  in  the  central  portions  of  the  gland, 
while  the  haemorrhages  and  infiltrations  of  leucocytes  and  bacilli  are  to 
be  best  seen  at  the  periphery.  The  bacilli  in  the  region  of  the  necrotic 
portions  assume  more  or  less  the  degenerative  forms  to  be  found  in  other 
parts.  In  fresh  pus  there  is  to  be  found  in  addition  to  polynuclear 
leucocytes  numerous  fully  degenerated  cells  and  debris  of  cells  and 
nuclei.  The  walls  of  the  vessels  and  capillaries  that  have  resisted 
the  disintegrating  process  are  thickened  and  dilated,  while  the  others 
which  have  given  way  and  from  which  the  blood  has  poured  out  are  in 
all  stages  of  necrosis,  some  consisting  of  mere  shreds  and  detritus.  The 
blood  is  coagulated  and  forms  a  network  both  within  and  without  the 


232  Pkiffue  in  the  Individual  [part  hi 

vessels,  or  is  broken  up  into  debris.     In  this  network  or  debris  are  nuclei 

of  cells,  disintegrated  leucocytes,  and  plague  bacilli.     The  capsule  of  the 

gland  is  broken  in  places  by  the  extravasation  of  blood  and  infiltration 

of  the  periglandular  tissue  with  bacilli  and  leucocytes,  and  its  fibres  are 

torn,    swollen    or   destroyed    so    as    to    be    indistinguishable    from    the 

affected  glandular  and  periglandular  tissues.     The  infiltration  of  the 

surrounding  connective  and    adipose    tissue,   when    not    haemon-hagic, 

is  essentially  cellulai-  and  contains  jxilynucleai-  leucocytes  in  different 

stages  of  disintegration,  and   large    numbers    of  plague   bacilli.     The 

oedema,  on  the  other  hand,  is  either  homogeneous  or  finely  granular 

in  character.     In  some  cases  there  is  not  much  haemorrhage  or  cellular 

infiltration    into     the     connective     and     adipose     tissue,    but    merely 

oedematous  fluid  swarming  with  plague  bacilli.     The  lymphatic  vessels 

in  the  vicinity  of  the  disintegrated  glands  are  usually  much  dilated, 

being  filled  with  lymph  cells  and  masses  of  plague  bacilli  mixed  with 

a  few   white   and  red  blood  corpuscles.     The   walls  of  the   vessel  are 

thirmer,  but  there  is  rarely  any  great  change  in  them,  though  occasionally 

the}'   are    filled    with    bacilli    and    leucocytes    or   are    necrotic   and    so 

disintegrated  as  to  form  detritus-like  masses. 

In  the  secondary  buboes  or  those  infected  by  plague  bacilli  conveyed 

to  them  by  the  circulation  the  chansres  in  the  glands  are 
Histological  .  °  .  .  , 

changes  in         not  nearly  so  pronounced.     The  parenchyma  is  uniformly 

secondary  hyperaemic,  the  capillaries  and  vessels  being  distended  with 

blood  in  which   will  be   found  plague  bacilli  in   varying 

numbers ;  the  fibrous  capsule  of  the  gland  remains  intact,  the  lymphatic 

vessels  and  lymph  channels  are   distended  with  lymph  cells,  and  the 

sinus  is  much  distended,  its  cells  being  swollen,  pale,  granular,  or  fatty. 

Within    the    sinus    are    often    polynuclear    leucocytes    and    red    blood 

corpuscles,  frequently  arranged  around  vessels  or  smaller  haemorrhages. 

Sometimes  the  sinus  is  gorged  with  blood  or  there  are  necrotic  centres 

with  granular  disintegration  of  the  cell  nuclei. 

In  buboes  which  have  healed  before  the  process  of  necrosis  or  deep- 
seated  suppuration  has  begun,  complete  resolution  takes  place,  leaving 
only  a  slight  but  general  thickening  of  the  capsule  of  the  parenchyma 
of  the  gland,  of  the  blood  vessels,  and  of  the  connective  tissue. 

The  most  characteristic  feature  of  cover-glass  and  sectional  prepara- 
The  plague  tions  fi'om  primary  buboes  is  the  enormous  number  of 
bacillus.  plague  bacilli  which  are  to  be  seen.     Even  when  necrosis 

of  the  gland  has  set  in,  and  there  are  few  bacilli  in  the  cover-glass  pre- 
parations, the  cultun's  funiisli  many  colonies  of  plague  bacilli. 


cii.  xn]  Morbid  Anatomy  and  Pathology  23o 

The  more  typical-shaped  bacilli  are  usually  to  be  found  in  the 
peripheral  portions  of  the  periglandular  tissues,  whereas  the  degenera- 
tive or  involution  forms  are  generally  in  those  parts  of  the  bubo  most 
affected,  where  the  plague  bacilli  have  destroyed  the  tissues,  and  which 
correspond  with  the  gland.  The  plague  bacilli  are  generally  extra- 
cellular, and  it  is  only  in  the  most  recent  infiltration  that  they  may  be 
seen  within  the  leucocytes.  In  secondary  buboes,  however,  the  plague 
bacilli  may  be  seen  within  the  swollen  oi'  desquamated  endothelium  of 
the  capillaries  and  lymphatic  vessels.  In  a  cover-glass  preparation  the 
size  and  form  of  the  bacilli  correspond  with  the  histological  changes  in 
the  bubo.  At  an  early  stage  the  typical  short,  thick  rod  forms  with 
rounded  ends,  often  exhibiting  a  capsule,  are  the  most  numerous.  They 
may  be  single,  in  pairs,  and  in  short  chains,  and  stain  deeply  at  the 
poles  with  carbol-fuchsin,  borax  methyl-blue,  Loeffler's  methylene  blue, 
or  other  aniline  dyes.  The  number  of  bacilli  taking  on  the  bi-polar 
staining  is  very  noticeable.  In  later  stages  the  bacillus  tends  to  lose 
its  plump  appearance  and  assumes  much  variety  in  shape  and  irregu- 
larity of  size.  There  is  to  be  seen  coccoid,  globular,  spherical,  bladder- 
like, tadpole,  and  sickle-shaped  forms,  which  differ  much  in  their  staining 
properties,  some  of  them  staining  but  faintly,  others  only  at  the  margin 
of  the  circumference  or  on  a  portion  of  the  rim,  and  others  remaining 
colourless. 

It  is  not  infrequent  to  meet  with  a  mixed  infection  in  plague, 
and  in  these  cases  the  pneumococcus  may  be  found  with  the  plague 
bacillus ;  or  the  streptococcus  or  staphylococcus  may  be  associated  with  it. 

It  frequently  happens  that  when  a  cover-glass  preparation  shows 
numerous  plague  bacilli  mixed  with  only  small  numbers  of  streptococci, 
diplococci,  and  staphylococci,  the  cultures  do  not  show  plague  bacilli. 
This  occurs  not  only  with  cultures  from  glands  and  buboes,  but  also 
with  cultures  from  the  spleen  and  liver  in  which  plague  bacilli  are 
distinct  and  numerous  in  smear  specimens.  Sometimes  when  only 
a  few  bacilli,  or  perhaps  none,  are  seen  on  the  cover-glass  preparation, 
cultures  may  show  colonies  of  plague  bacilli.  It  is  important,  therefore, 
as  pointed  out  by  Albrecht  and  Ghon^  when  it  is  a  question  of  doubtful 
diagnosis,  that  both  cultures  and  cover-glass  preparations  should  be 
made,  and  they  should  be  supplemented  by  inoculation  of  animals. 

Another  important  point  is  that  though  the  bacillus  is  often  not  to 

1  "  Ueber  die  Beulenpest  in  Bombay  im  Jahre  1897."  Gesatiniitbericht  der  von  der 
Kaiserlichen  Akadeinie  der  Wisse  use  haft  in  U'ien  zuiii  Stitditiin  der  lieulenpeat  iiach 
Indien  eiitsendeter  Commission.     Vienna,  1898,  p.   508. 


234  Plague  in  the  Individual  [part  m 

be  found  in  a  suppurating  bubo,  yet  sujjpuration  does  not  necessarily 
destroy  its  vitality.  It  has  been  found  in  cases  of  this  description  in 
man  and  also  in  animals.  The  Austrian  Commission  first  drew  atten- 
tion to  this^  In  this  connection  two  cases  are  mentioned  by  Dr  Choksy^ 
of  Bombay,  in  which  iliac  buboes  were  opened  through  the  abdominal 
wall  on  the  48th  day  of  illness,  and  the  pus  was  found  to  contain  plague 
bacilli  in  an  active  state  and  capable  of  growth  when  cultured. 

Plague  bacilli  are  not  only  present  in  the  buboes  and  adjacent 
tissues,  but  in  septic  cases  they  are  also  present  in  the  blood,  in  the 
glands,  in  the  lungs,  liver,  kidney,  in  the  bone  marrow,  in  the  bile,  in 
the  urine  and  faeces,  in  the  peritoneal  fluid,  and  in  fact  in  every  organ 
and  secretion  of  the  body. 

The  spleen  is  enlarged  and  congested,  having  the  capsule  distended, 
of  a  light  grey  opacity  and  sometimes  marbled  with  hae- 
mon-hages.  On  section  it  is  seen  to  be  much  engorged, 
is  a  deep  red,  chocolate-brown  or  purple  colour,  and  has  a  granular 
appearance.  The  Malpighian  bodies  are  swollen  and  engorged,  the 
substance  may  be  fairly  firm  or  friable  and  soft,  or  it  may  be  almost 
diffluent. 

Histologically  the  changes  in  the  spleen  are  similar  to  those  in  the 
lymphatic  glands,  and  consist  of  haemorrhages,  inflammations,  infiltra- 
tion of  leucocytes  and  bacilli,  and  necrosis.  The  infiltration  of  the  pulp 
and  blood  spaces  with  blood,  polynuclear  leucocytes  and  epithelial  cells, 
renders  the  spongy  structure  of  the  spleen  indistinct.  The  Malpighian 
corpuscles  remain  intact.     The  trabiculae  are  mostly  swollen. 

Small  necrotic  centres  are  frequently  to  be  seen  surrounded  by 
numerous  plague  bacilli.  They  are  formed  by  the  coagulating  and 
disintegrating  action  of  the  bacilli,  and  are  composed  of  the  debris  of 
the  disintegrated  walls  of  the  blood  vessels  and  the  detritus  of  coagu- 
lated blood.  Plague  bacilli  have  been  found  in  the  spleen  of  a  patient 
who  died  on  the  52nd  day  of  illness  I 

The  pericardial  cavity  usually  contains  a  large  quantity  of  blood- 
circuiatory  stained  or  straw-coloured  f^uid.  Ecchymoses  occur  on  the 
system.  pericardium  and  endocardium.     The  heart  muscle  is  pale, 

soft,  and  friable,  and  is  in  a  condition  of  cloudy  swelling  or  fatty  de- 
generation. The  right  side  is  usually  distended  with  dark  red  blood 
and  coagulated  to  form  soft  clots,  or  is  in  a  semi-fluid  condition.     On 

^  "  Ueber  die  Beulenpest  in  Bombay  im  Jahre  1897,"  p.  510. 

-  The  Treatment  of  Plague  with  Professor  Lustig's  Serum.    By  N.  H.  Choksy,  M.D.,  1903. 

3  H,  Albrecht  u.  A.  Ghon.     "  Ueber  die  Beulenpest  in  Bombay  iiu  Jahre  1897,"  p.  532. 


CH.  XII J         Morbid  Anatomi/  and  Pathologif  235 

the  valves  may  occasionally  be  observed  haemonhagic  growths.  The 
blood  itself  is  in  a  state  of  leucocytosis  of  the  polynuclear  variety,  and 
generally  contains  plague  bacilli.  It  has  very  little  tendency  to  coagu- 
late and  remains  fluid.  It  is  usually  of  a  very  dark  colour.  The  great 
veins  of  the  thorax  and  abdomen  are  distended  with  dark  blood,  and 
there  is  a  general  distension  of  the  veins  and  smaller  blood  vessels, 
accompanied  by  large  and  small  haemorrhages.  Haemorrhages  are,  in 
fact,  one  of  the  characteristics  of  the  disease.  There  are  haemorrhages 
in  nearly  every  organ  of  the  body,  on  the  serous  and  mucous  coats  of 
the  cavities,  and  in  and  around  the  specially  affected  lymphatic  glands. 
The  plague  bacilli  and  their  toxines  appear  to  have  a  peculiar  coagu- 
lative  and  necrotic  effect  on  the  walls  of  the  smaller  veins  and  minute 
capillaries,  leading  to  exudations. 

The  veins  of  the  trunk  when  cut  open  display  numerous  small 
punctated  haemorrhages  which,  the  nearer  the  veins  approach  the 
vicinity  of  a  bubo,  become  haemorrhagic  patches  of  considerable  size. 
It  has  already  been  stated,  that  the  walls  of  large  veins  in  the  region 
of  primary  buboes  are  much  affected.  In  those  veins  which  are  em- 
bedded in  the  sero-sanguinolent,  gelatinous,  or  haemorrhagic  infiltration, 
and  which  are  thus  subjected  to  the  solvent  action  of  the  plague 
bacillus  and  its  glutinous  toxines,  the  outer  walls  become  destroyed, 
and  the  tunica  intima  exhibits  large  haemorrhagic  and  suffused  patches 
with  erosions.  In  the  event  of  perforation  taking  place  through  the 
intima,  the  copious  haemorrhagic  and  oedematous  effusions  crowded 
with  bacilli  find  their  way  into  the  blood  stream  :  microscopical  examina- 
tion shows  that  the  coats  of  the  venous  walls  are  separated  by  masses  of 
blood,  that  the  endothelium  is  taken  off  or  has  disappeared,  and  that 
plague  bacilli  are  present  in  great  numbers.  Venous  haemorrhage  of 
this  kind  only  occurs  as  a  rule  when  the  lymphatic  glands  are  in  an 
advanced  state  of  change. 

The  mucous  membrane  of  the  larynx,  trachea  and  the  large  bronchi 
The  respira-  exhibit  a  more  or  less  catarrhal  condition.  In  some  cases 
tory  system.  of  cervical  bubo  or  in  tonsillar  plague  the  exudation  may 
extend  to  the  glottis,  causing  oedema  of  one  or  both  folds  of  this  organ. 
The  effusion  presents  the  same  yellowish  jelly-like  appearance  character- 
istic of  oedema  in  the  vicinity  of  the  bubo.  Microscopically  it  consists 
of  homogeneous,  finely  granular  fluid  containing  leucocytes,  red  corpuscles 
and  plague  bacilli. 

In  all  forms  of  plague  the  lungs  are  congested  and  oedematous,  and 
on  section  a  sero-frothy  mucus  exudes  from  them.     There  are  small 


236  Plague  in  ihc  TitdivUlual  [part  m 

haemorrhages  into  the  lungs  and  more  or  less  extensive  pleural  hae- 
morrhages in  the  region  of  the  diaphragm,  on  the  chest  walls,  and  on 
the  surface  of  the  lung.  Microscopically  the  vessels  of  bronchi,  lung 
tissue  and  pleura  are  distended  with  blood,  plague  bacilli  are  to  be  seen 
in  the  lung  oedema,  and  especially  wherever  there  are  haemorrhages. 

In  the  pneumonic  form  of  plague  first  described  by  Childe',  which 
is  of  a  primary  character  and  usually  unaccompanied  by  buboes,  and  in 
the  pneumonic  form  of  a  secondary  nature  with  buboes,  the  lungs  are  the 
seat  of  a  well-marked  disseminated  broncho-pneumonia.  In  pneumonic 
plague,  in  addition  to  the  great  engorgement  and  oedema  of  the  lungs 
which  exist  in  other  forms  of  plague,  the  bronchi  are  inflamed  and 
haemoiThagic,  and  filled  with  a  blood-stained  frothy  mucus,  and  the  lung 
tissue  contains  numerous  pneumonic  patches  scattered  throughout  its 
substance.  These  patches  vary  in  size  fi'om  a  pea  to  that  of  an  egg,  and, 
when  superficial,  are  raised  above  the  siirface,  forming  small  tumours ;  the 
pleura  over  them  generally  shows  signs  of  inflammation  and  is  covered  with 
a  fibrinous  exudation.  They  are  of  a  deep  red,  pink  or  reddish-grey  colour, 
solid,  airless,  and  sink  in  water,  and  they  are  separated  fi"om  the  surround- 
ing crepitant  lung  tissue  by  a  distinct  ring  of  engorgement.  The  patches 
are  lobular  in  type,  and  as  a  rule  are  distinct,  but  they  may  be  con- 
fluent so  as  to  form  large  areas  or  even  afl:ect  the  whole  of  one  lobe 
and  exhibit  the  appearance  of  that  of  a  croupous  pneumonia.  In  these 
cases  the  consistence  of  the  part  is  friable,  the  colour  is  of  a  chocolate 
hue,  and  on  pressure  there  exudes  from  the  lung  a  prune-coloured 
liquid  rich  in  plague  bacilli.  The  bronchial  glands  are  engorged, 
swollen,  and  are  often  haemorrhagic.  Microscopical  examination  of  the 
pneumonic  patches  shows  the  alveoli  to  contain  catarrhal  epithelium, 
leucocytes,  blood  cells,  granular  debris,  and  fibrils  of  destroyed  septa, 
together  with  a  homogeneous  coagulated  mass  of  oedematous  fluid  and  a 
large  number  of  plague  bacilli  occasionally  mixed  with  pneumococci  and 
streptococci.  The  bronchioles  and  bronchi  are  also  full  of  plague 
bacilli,  which  during  life  appear  in  the  sputum ;  portions  of  the  patches 
may  have  iindergone  necrosis.  The  fibrinous  exudation  in  the  pleura 
contains  plague  bacilli.  The  patches  in  secondary  pneumonia  are  fre- 
quently of  the  nature  of  small  metastatic  infarcts. 

There  is  an  interesting  record  of  a  post-mortem  made  b)'  Dr 
Thomson  on  plague  in  the  Great  Plague  of  London.  It  was  evidently 
of  the  pneumonic  type ;  it  is  that  of  a  dissection  of  a  young  man  who 

^  Report  by  Surgeon-Major  Lyons,  I. M.S.,  of  Bombay,  President  of  the  Plague  Research 
Committee. 


CH.  xii]         Morbid  Anatomy  and  PatJiolofjy  :>37 

died  of  plague.  It  is  recorded  that  "  the  superficies  of  the  lungs  were 
stigmatized  with  several  large  ill-favoured  marks,  much  tumefied  and 
distended,  the  inward  part  being  pertunded  with  my  knife  a  sanious 
dreggy  corruption  issued  forth  and  a  pale  ichor  destitute  of  any  bloods" 
T>T  Thomson  was  himself  attacked  with  plague  the  next  day  after 
the  dissection,  but  recovered  and  got  up  on  the  8th  day ;  he,  however, 
had  a  relapse.  Three  other  persons  were  attacked  in  his  house  but  all 
recovered. 

The  liver  may  be  enlarged  or  normal  in  size  and  engorged  with 
blood,  but  the  parenchyma  is  generally  pale,  soft,  and 
tiiable  and  in  a  state  of  cloudy  swelling  or  fatty  degenera- 
tion. Yellow  necrotic  patches  are  often  seen  in  its  substance,  and 
especially  on  its  upper  surface.  On  microscopical  examination  the 
capillaries  are  seen  to  be  distended  and  may  show  colonies  of  plague 
bacilli  with  leucocytes,  both  of  which  are  particularly  numerous  in  and 
near  the  yellow  necrotic  patches,  as  well  as  in  numerous  ecchymoses, 
which  may  be  often  seen  on  the  surface  of  the  liver  and  on  the  glissonic 
capsule. 

The  gall-bladder  has  its  mucous  membrane  not  infrequently  studded 
with  small  multiple  haemorrhages,  which  sometimes  joining  give  it 
a  dark,  marbled  appearance.  These  minute  haemorrhages  may  extend 
into  the  mucous  membrane  of  the  bile-ducts.  Plague  bacilli  are  in 
these  haemorrhages  as  well  as  in  the  bile. 

The  pancreas  may  be  congested  but  is  otherwise  normal  in  ap- 
pearance. 

The  mucous  membrane  of  the  pharynx  and  oesophagus  are  generally 
Alimentary  congested  and  inflamed  and  the  seat  of  petechiae.  The 
canal.  tonsils  may  be  normal  but  sometimes  they  are  swollen  and 

haemorrhagic,  presenting  on  section  the  mottled  appearance  seen  in 
buboes.  In  some  cases  the  tonsil  may  be  surrounded  by  an  oedematous 
infiltration,  extending  into  the  palatine  arch  or  to  the  glottis.  In  other 
cases  both  pharynx  and  tonsil  may  be  covered  by  a  pseudo-diphtheritic 
dirty-yellowish  membrane  which  undergoes  necrosis.  This  destructive 
process  is  due  to  infiltration  of  plague  bacilli,  often  mixed  with  other 
pyogenic  microbes.  In  connection  with  this  condition  of  the  tonsils  the 
lymph  glands  of  the  neck  are  generally  affected  and  plague  bacilli  are 
to  be  found  in  the  sputum. 

It  may  be  here  pointed  out  that  in  a  number  of  experiments  on 

^  "Loimotomia  on  the  Test,"  by  George  Thomson,  M.D.,  166G. 


238  Plague  in  the  Individual  [part  hi 

animals  already  mentioned,  in  which  plague  was  produced  by  feeding 
with  plague  bacilli,  the  pharynx  and  cervical  glands  were  much 
affected. 

■  Small  punctate  haemorrhages  occur  in  the  stomach  and  intestines  in 
the  mucous  coat,  and  extra vasated  blood  is  occasionally  to  be  found  in  the 
stomach.  At  times  the  haemorrhages  in  stomach  and  intestines  may  be 
extensive  and  the  mucous  membrane  intensely  inflamed  and  covered 
with  mucus.  In  these  cases  there  is  an  infiltration  into  or  oedema  of 
the  sub-mucous  coat.  The  solitary  glands  and  Peyer's  patches  are  often 
congested  and  swollen,  the  patches  being  denuded  of  their  epithelium 
and  sometimes  ulcerated.  Ulcerations  may  occur  on  the  ileo-caecal 
valve.  In  the  haemorrhages  are  plague  bacilli.  There  are  extrava- 
sations into  the  mesentery.  The  mesenteric  and  retro-peritoneal  glands 
sometimes  show  much  swelling,  inflammation,  and  haemorrhagic  in- 
filtration. This  was  more  frequent  in  Hongkong  than  elsewhere. 
There,  not  infrequently,  were  observed  extensive  extravasations  of  blood 
in  the  mesentery,  and  in  the  majority  of  cases  more  or  less  enlargement 
and  inflammation  of  the  mesenteric  glands,  which  varied  from  a  white  to 
a  purple  colour,  and  were  sometimes  surrounded  by  a  sero-sanguineous 
infiltration  similar  to  that  of  an  external  bubo. 

The  connective  tissue  around  the  kidneys  is  frequently  infiltrated 
The  urinary  with  a  large  mass  of  extra  vasated  blood  of  a  tarry  colour, 
system.  The  kidneys  are  swollen,  purplish  in  colour,  and  with  the 

surface  dotted  with  petechiae.  The  stellate  veins  are  visible,  the  capsule 
nsually  adherent,  and  the  kidney  substance  pale  and  soft  from  parenchy- 
matous and  fatty  degeneration.  The  cortical  portion  is  the  most  affected, 
being  studded  more  or  less  by  yellow  necrotic  foci,  attaining  at  times 
the  size  of  a  pea.  These  foci  contain  a  very  large  number  of  plague 
bacilli  and  polynuclear  leucocytes. 

Sometimes  the  glomeruli  are  swollen  and  the  capillaries  may  have 
undergone  necrotic  changes.  There  are  haemorrhages  into  the  mucous 
membrane  of  the  pelvis,  and  occasionally  these  are  so  extensive  as  to 
break  through  the  mucons  membrane  and  pass  into  the  ureter,  coagula 
of  blood  being  then  found  in  the  pelvis  of  the  kidney,  the  ureter  and 
bladder.  Plague  bacilli  are  to  be  found  in  these  haemorrhages ;  the 
ureter  besides  containing  coagulated  blood  has  on  its  mucous  membrane 
petechiae.  The  bladder  is  generally  contracted,  and  its  mucous  mem- 
brane the  seat  of  numerous  small  haemorrhages  which  contain  plague 
bacilli.  Owing  to  the  haemorrhage  in  the  kidneys  and  along  the  urinary 
tract  the  urine  as  a  rule  contains  plague  bacilli. 


CH.  xii]  Aiito2)sies  239 

The  suprarenal  capsule  may  be  normal  although  engorged,  or  it  may 
be  the  seat  of  necrotic  centres. 

The  cerebral  membranes  are  congested  and  the  venous  sinuses 
Nervous  engorged  with  blood.    Petechiae  or  ecchymoses  may  be  seen 

system.  jj-j  ^j^g  dura  mater.     There  may  be  extravasation  of  blood 

or  effusion  of  serous  fluid  into  the  cavity  of  the  arachnoid  or  under  that 
membrane.  The  cortex  of  the  brain  may  be  in  a  state  of  congestion, 
while  the  substance  of  the  brain  shows  an  unusual  number  of  red  points 
in  it  indicating  increased  vascularity.  It  may  also  be  oedematous,  but 
beyond  slight  softening  of  the  tissue  there  appears  to  be  no  marked 
lesion  in  the  brain  substance.  The  spinal  cord  when  examined  is  found 
to  be  congested. 

Bubonic  plague,  judged  by  the  pathological  changes  observed  in  the 
dead  body,  is  a  disease  both  of  the  lymphatic  and  vascular 
system,  on  which  the  plague  bacilli  and  its  toxines  when 
brought  in  contact  with  them  in  large  numbers  and  quantity  exercise 
an  inflammatory,  coagulative  and  necrotic  effect.  The  microbic  agent 
and  its  toxines  thus  acting  lead  to  enlargement  of  the  external  and 
internal  lymph  glands,  necrosis  of  their  substance  and  often  haemorrhage 
or  infiltration  into  the  surrounding  tissues,  to  dilatation  of  the  veins 
and  capillaries,  to  destruction  of  their  walls,  to  haemorrhagic  extravasa- 
tions into  nearly  every  part  of  the  body,  to  enlargement  and  en- 
gorgement of  various  organs,  and  to  metastatic  parenchymatous  de- 
generation in  the  liver,  spleen,  and  kidneys.  Pneumonic  plague  differs 
from  bubonic  in  having  these  changes  more  concentrated  on  the  lung 
tissues  and  its  lymphatic  system  than  on  the  other  lymph  glands  of  the 
body. 

Autopsies. 

Malay  girl,  aged  7  years.  Nothing  on  skin.  On  making  an  incision 
into  skin  over  inguinal  region,  left  inguinal  <jland  found  to  be  the  size  of 
a  large  Brazil  nut ;  surface  haemorrhagic  on  one  portion.  On  section 
upper  half  dark  maroon  or  coffee  colour,  lower  half  dark  grey  with  streaks 
of  haemorrhage  passing  from  the  surface  to  the  interior.  Around  the 
gland  a  large  amount  of  haemorrhagic  infiltration  extending  well  above 
Poupart's  ligament  and  also  down  to  nearly  one- third  of  the  upper  part 
of  the  thigh,  matting  together  in  its  fibrinated  tissue  a  number  of 
maroon-coloured  glands.  The  oedema  extends  beyond  this  infiltration. 
The  infiltration  and  oedema  of  the  left  inguinal  glands  extend  to  the 


240  Plague  in  the  Individual  [part  hi 

iliac  glands  inside  the  abdoinon  which  are  also  haemorrhagic  and  coffee- 
coloured,  but  there  is  no  extensive  oedema  around  these  iliac  glands ;  the 
right  iliac  glands  healthy. 

The  right  inguinal  region  enlarged  but  not  so  much  as  the  left ; 
periphery  of  gland  haemorrhagic,  the  central  portion  being  greyish  in 
colour.  Left  and  right  lungs  not  pneumonic  but  coffee-coloured.  The 
spleen  enlarged,  elastic  and  much  engorged.  Plague  bacilli  in  glands, 
lungs,  and  spleen. 

Malay  girl,  aged  12  years.  Taken  ill  with  fever  and  difficulty  of 
breathing,  and  j^ain  in  the  abdomen,  was  ill  for  3  days,  no  buboes. 
Died  suddenly ;    diagnosis,  inflammation  of  the  bowels. 

Post-mortem.  Glands  in  both  groins  slightly  enlarged  and  haemor- 
rhagic. Fat  of  right  groin  blood-stained.  Femoral  vein  deeply  congested. 
Glands  in  iliac  region  congested.  Glands  of  mesentery  enlarged  and  of 
a  maroon  appearance.  Small  intestine  inflamed  and  congested.  Langs 
not  patchy,  but  with  one  lobe  on  either  side  deeply  congested  and  full  of 
a  prune-coloured  juice.  Plague  bacilli  found  in  the  lungs,  glands,  and 
other  organs  of  body. 

Hindu,  male,  aged  28  years.  Fell  ill  on  17th  July.  Admitted  to 
hospital  on  the  evening  of  the  21st. 

History.  On  17th  July,  evening,  was  suddenly  attacked  with 
vomiting  accompanied  with  fever  and  very  bad  headache.  About  the 
same  time  he  felt  a  stabbing  pain  in  the  left  groin  and  noticed  that  a 
swelling  was  there.  The  next  day  he  was  very  prostrated  and  almost 
uncon.scious. 

Present  state.  Is  in  great  agony.  Pulse  cannot  be  counted.  Tem- 
perature 101 'IF.;  typical  plague  tongue,  surface  covered  with  yelhjwish- 
brown  coating  with  small  red  points  in  it.  In  left  femoral  region  a  bubo, 
size  of  a  large  hen's  ag^.  Skin  over  bubo  red  and  much  infiltrated. 
Patient  died  one  hour  after  admission. 

Post-mortem.  Skin  in  femoral  region  haemorrhagically  discoloured. 
Bubo  size  of  a  hen's  egg ;  on  section  there  oozes  out  a  bloody  oedematous 
gelatinous  fluid ;  the  periglandular  tissue  of  a  gelatinous  nature  with  a 
great  infiltration  of  blood.  All  the  lymphatic  glands  of  this  region  matted 
together  forming  one  large  bubo,  which  on  section  is  of  a  dark  violet 
colour;  lymijhatic  glands  in  right  region  are  swollen  and  form  small 
separate  buboes.  All  the  lymphatic  glands  in  the  body  are  swollen  and 
congested.  On  ojjoning  chest  lungs  contract  normally,  lungs  oedematous: 
interlobular  ecchymoses.  In  left  lung  on  section  a  few  .small  rose-coloured 
patches;  on  pressure  a  red-yellow  fluid  devoid  of  air  oozes  out.     Over 


CH.  XII ]  Autopsies  -241 

the  heart  iiuuicruu.s  ecchyinoses.  Heart  small,  valves  and  openings 
normal.  Spleen  very  much  enlarged.  Capsule  of  spleen  very  distended. 
On  section  the  pulp  is  swollen  and  friable.  Kidneys  slightly  enlarged. 
On  section  surface  shows  swollen  cortex,  discoloured  and  with  in- 
distinct picture.  Liver  enlarged,  structure  indistinct.  Stomach  normal. 
Mucous  membrane  of  ileum  very  much  injected,  but  no  ulcerations. 
In  fossa  iliacum  a  recto-peritoneal  bubo  of  walnut  size  on  right  side ; 
mesenteric  glands  swollen  and  congested. 

Bacteriological  examination.  Numerous  plague  bacilli  in  direct 
preparations  from  bubo  and  glands  on  right  side,  blood,  and  spleen. 
All  give  ])ure  cultures. 

Hindu,  male,  aged  25  \  Admitted  on  March  6th  and  died  the  same 
day.     History  unknown. 

Post-mortem  next  morning. 

Well-developed,  well-nourished  body.  Rigor  mortis  almost  dis- 
appeared, no  petechiae  visible.  Conjunctivae  injected,  mucous  mem- 
brane of  the  mouth  pale.  Under  Poupart's  ligament,  near  the  median 
line,  a  lymphatic  gland  larger  than  a  hazel-nut  can  be  felt. 

No  oedema  of  the  lower  extremities.  The  skin  of  the  soles  much 
fissured;  no  exterior  injuries  perceptible.  The  Igrnphatic  glands  in 
both  submaxillary  regions  the  size  of  beans,  and  on  section  dark  red  and 
juicy.  Both  tonsils  enlarged,  on  section  exhibit  many  yellow  spots;  the 
left  side  is  infiltrated  with  a  soft  medullary  substance,  and  is  very  juicy, 
dark  red,  and  sprinkled  with  yellow.  The  mucous  membrane  of  the 
pharynx  is  reddish-violet  and  swollen,  the  mucous  membrane  of  the  epi- 
glottis is  much  reddened  and  swollen.  The  follicles  at  the  base  of 
the  tongue  reddened  and  enlarged ;  numerous  punctiform  ecchymoses 
in  the  larynx  and  at  the  root  of  the  tongue.  Lungs  congested,  and  on 
section  frothy  and  slightly  oedematous.  Pericay'diuni  contains  a  small 
amount  of  clear  serous  fluid,  epicardium  dotted  with  ecchymoses  size  of 
millet  seeds ;  heart  normal  in  size,  fibrinous  coagula,  left  side  paren- 
chymatous, pale  and  soft.  The  mucous  membrane  of  the  trachea  and 
the  large  bronchia  somewhat  reddened.  The  lymphatic  glands  at  the 
bifurcation  as  large  as  beans  and  infarcted.  Alimentary  canal  not  patho- 
logically changed.  Liver  soft,  but  normal  in  size  ;  on  section  moderately 
haemorrhagic,  flecked  with  yellow  ;  generally  brownish-grey,  the  outlines 
of  the  lobes  obliterated.  The  gall-bladder  filled  with  dark  bile,  mucous 
membrane  thin  and  yellowish-brown.  Spleen  very  soft,  and  dark  red 
on  section  ;  pulp  oozy,  stroma  not  increased,  follicles  recognisable,  in 
1  Case  extracted  from  the  Report  of  the  Austrian  Plague  ComuiisgiQu. 

s.  16 


242  Flar/ur  in  IIk    Individual  [part  hi 

parts.  Right  kidney  somewhat  eiilarcred  and  congested  on  section ; 
cortex  swollen,  sprinkled,  and  striped  with  greyish-yellow  and  red,  well 
bordered  otf  from  the  pyramids,  the  periphery  of  the  latter  being  in- 
jected with  vivid  red.  Condition  of  left  kidney  similar.  Both  renal 
pelves  normal.  The  bladder  filled  with  yellowish  urine,  its  raucous 
membrane  whitish.  The  deep  wfniinal  lyiiiplmtic  r/lands  at  the  interior 
femoral  ring  on  the  left  side  the  size  of  hazel-nuts:  three  lymphatic 
glands  about  the  size  of  beans  in  their  vicinity.  The  connective  tissue 
round  the  latter,  and  round  the  iliac  vessels,  is  wet  with  gelatinous 
material,  and  sanguineously  infiltrated,  as  is  also  the  vicinity  of  both 
ureters.  There  are  numerous  confluent  dark  bluish-red  haemorrhages 
in  the  wall  of  the  left  femoral  vein,  composed  of  smaller  haemorrhages 
about  the  size  of  millet  seeds,  and  which  infiltrate  almost  the  entire 
intima  of  the  region.  The  superficial  inguinal  lymphatic  glands  of  the 
left  side  considerably  swollen,  moderately  hard,  protruding  on  incision, 
haemorrhagic  and  congested,  and  infiltrated  with  yellow  spots. 

1.  Three  forms  of  bacteria  are  found  in  cover-glass  preparations 

of  the  left  tonsil,  but  not  in  very  great  numbers.     A  long, 
Bacterio-  .  "    "  .  .  , 

logical  con         slender  species  of  bacillus  is  most  prominent,  and  ovoid  or 

*^*^°°'  longish  forms  of  typical  plague  bacilli  are  present  in  some- 

what less  numbers  ;  they  take  bipolar  staining  well,  and  most  lie  singly, 
more  rarely  as  diplobacilli.  The  third  species,  present  in  least  numbers, 
is  formed  as  a  minute  rod,  likewise  with  bipolar  stain,  and  which  re- 
sembles the  smallest  diplococcus.  No  plague  colonies  are  visible  in  the 
cultures,  but  there  are  numerous  colonies  of  the  coli  group  and  the 
spore-bearing  rodlets. 

2.  A  haemorrhagically  infiltrated  cervical  lymphatic  gland  from 
the  left  submaxillary  region  exhibits,  microscopically,  typical  plague 
bacilli  in  fairly  large  numbers,  lying  singly  or  as  diplococci,  and  of 
roundish  or  <jval  form ;  in  addition  to  bacilli  exhibiting  good  bipolar 
staining  there  arc  paler,  ovoid,  and  large,  roundish,  inflated  forms. 

The  cultures  are  contaminated  and  are  therefore  not  used. 

3.  Numerous  plague  bacilli  are  exhibited  microscopically  in  the 
juice  of  the  spleen  ;  they  mostly  lie  alone,  being  of  round,  oval,  or  longish 
form,  with  bipolar  stain,  or  are  only  stained  faintly,  and  of  various  forms. 

The  cultures  exhibit  numerous  plague  colonies  exclusively. 

4.  Cover-glass  preparations  of  a  haemorrhagically  infiltrated  super- 
ficial inguinal  lymphatic  gland  of  the  right  side  exhibit  copious  masses 
of  plague  bacilli  in  the  same  form  and  order  as  3,  but  the  degenerative 
forms  are  more  numerous ;  every  form  is  present,  even  the  large  inflated 


CH.  xii]  Autopsies  243 

forms,  of  which  frecjuently  only  the  outlines  are  sbained  (annular 
forms). 

On  using  Pittfield's  mixture  no  distinct  capsular  appearances  are 
seen,  but  one  may  observe  a  faintly  tinted  violet  area  in  a  number  of 
bacilli ;  this  area  is  more  or  less  distinctly  bordered,  or  there  may  be 
an  unstained  area  which  is  bordered  off  by  a  stained  contour. 

The  cultures  exhibit  very  numerous  colonies  of  the  plague  bacillus, 
and  6  colonies  of  the  unknown  species  of  bacillus  (contamination). 

1.  Enlarged  superficial  l>/niphatic  gland  fro'ni  the  left  inguinal 
Histological  region.  Only  isolated  follicles  in  the  cortical  layer  are  left 
condition.  Qf  \\-^q.  parenchyma,  also  a  few  septa  of  the.  connective 
tissue  closely  infiltrated  by  poly  nuclear  leucocytes,  and  ninnerous  small 
and  large  vessels  full  of  blood,  the  walls  of  which  in  places  are  closely 
infiltrated  by  leucocytes. 

The  enlargement  of  the  gland  seems  mostly  to  have  been  caused  by 
enormous  masses  of  plague  bacilli,  which  infiltrate  it  entirely  in 
connected  masses,  cutting  into  the  vessels  in  all  directions  and  including 
relatively  few  leucocytes.  In  between  there  are  small  haemorrhages  in 
all  directions,  often  round  vessels  with  entirely  homogeneous  walls. 
These  (veins,  arteries,  and  lymph  vessels)  often  contain  numerous 
polynuclear  leucocytes  and  numbers  of  bacilli. 

The  fibrous  capsule  of  the  lymphatic  gland  infiltrated  by  copious 
round-cell  and  bacillar  infiltration,  so  that  there  is  no  sharp  border 
between  the  gland  and  its  vicinity.  In  the  latter  also  enormous 
numbers  of  bacilli  and  copious  confluent  haemorrhages  are  found.  The 
adipose  tissue,  especially,  appears  to  be  so  closely  infiltrated  with 
bacilli  in  parts  that  its  meshes  seem  to  be  surrounded  by  broad  lines  of 
bacilli.  Only  slight  nuclear  atrophy  or  cellular  disintegration.  The 
plague  bacilli  only  stain  slightly  with  methylene  blue,  and  particularly 
where  they  lie  close  together  in  large  masses  exhibit  pronounced  coccus 
forms  (separate  ones  being  remarkably  large).  They  are  situated 
extra-  and  intracellularly.  There  are  no  other  bacteria,  and  only  very 
little  fibrine  is  perceptible. 

2.  Lymphatic  gland  from  the  left  side  of  neck  (fossa  submaxillaris) 
about  the  size  of  a  bean.  The  gland  exhibits  extensive  hyperaemia, 
the  numerous  capillaries  and  small  vessels  being  quite  full  of  blood. 
There  are  only  a  few  isolated  extravasations  of  blood.  The  sinuses 
somewhat  dilated,  and  in  them,  here  and  there,  single  red  blood  cells 
and  polynuclear  leucocytes  in  moderate  numbers  are  seen.  Attention  is 
immediately  arrested  by  the  size  of  the  endothelial  cells  and  their  nuclei 

16—2 


244  Phajui'  in  tltr  liHUvidual  [part  iii 

which  belong  to  the  fine  lynij)h  channels  of  the  sinus  and  cover  the 
follicles  and  rays  of  medullary  substance,  and  which  almost  entirely  fill 
the  sinus.  Thev  are  frequently  of  epithelial-like  form,  having  either 
one  or  several  faintly  stained  nuclei  with  several  nucleoli  which  appear 
to  be  round  or  lobulate. 

The  end(jthelium  of  the  blood  vessels  is  also  large,  with  large  pale 
nuclei.  In  sections  stained  with  alkaline  methylene  blue,  plague  bacilli 
are  seen,  more  or  less  abundant  in  number,  in  each  of  the  numerous 
blood  vessels;  they  are  in  diplococcus  form,  and  are  always  adjacent  to 
or  within  the  endothelial  cells.  Only  a  few  isolated  groups  are  found  in 
the  sinus. 

3.  Sections  through  the  left  tonsil  exhibit  the  same  condition 
generally  as  that  of  the  gland  described  above :  extensive  hyperaemia 
with  increase  of  the  polynuclear  leucocytes;  in  addition,  Avell-defined 
bordering  off  of  the  adenoid  tissue  from  the  surrounding  connective 
tissue,  and  healthy  epithelial  covering.     No  haemorrhages. 

Here,  also  in  almost  every  dilated  blood  vessel,  there  are  large  or 
small  agglomerations  of  plague  bacilli :  adjacent  to  the  endothelium,  or, 
doubtless,  also  within  it.  There  are  small  groups  consisting  of  only  a 
few  bacilli  in  the  adenoid  tissue  and  always  in  an  intracellular  position. 
The  cells  surrounding  them  are  large  endothelial  cells  that  are  unfilled 
collapsed  blood  or  lymph  capillaries. 

4.  The  histological  examination  of  somewhat  enlarged  follicles  at 
the  base  of  the  tongue  shows  the  same  results.  The  so-called  germinal 
centre  is  copiously  infiltrated  with  polynuclear  leucocytes.  The  con- 
dition as  regards  the  plague  bacillus  is  also  analogous. 

5.  Spleen  exhibits  histologically  a  very  copious  infiltration  of 
polynuclear  leucocytes  in  the  region  of  the  pulp,  as  well  as  severe 
hyperaemia.  Many  pulp  cavities  remain  intact  and  filled  with  blood, 
the  endothelium  cells  very  large;  in  those  parts  where  there  exist 
sanguineous  infiltrations  of  the  pulp,  they  are  mixed  irregularly  with 
the  extravasated  blood.  Follicles  frequently  remarkably  small,  and  free 
from  bacilli.  The  spleen  substance  is  infiltrated  with  enormous  masses 
of  plague  bacilli,  which  are  sometimes  intracellular.  At  some  places 
there  are  isolated,  long,  thick  rods  (saprophytes)  which  stain  well  with 
methylene  blue.  Trabeculae  somewhat  spread,  faintly  coloured,  and 
having  irregular  granulations  in  parts ;  their  nuclei  likewise  very  pale. 

6.  Kidney.  The  epithelial  cells  of  the  renal  cortex,  particularly 
the  tubuli  contorti,  either  large  and  unshapely  as  if  swollen,  with  faintly 
coloured  nuclei,  or  without  nucleus,  in  which  case  the  borders  can  hardly 


CH.  xii]  Autojjsies  245 

be  distinguished  or  are  entirely  obliterated  and  contain  drops  of  fat  of 
various  size.  In  the  interior  of  the  tubules  numerous  indistinctly 
granulated  masses  stained  with  eosin.  The  capillaries  in  part  greatly 
dilated  and  there  are  small  extravasations  of  blood  between  the  tubuli 
in  the  interstitial  connective  tissue.  The  glomeruli  large ;  sometimes 
filled  with  blood ;  the  separate  capillary  loops  dilated.  The  nuclei  of 
the  epithelia  of  Bowman's  capsule  very  numerous  and  large.  No 
particular  changes  in  the  renal  pyramids.  Small  groups  of  plague 
bacilli  to  be  seen  in  the  dilated  capillaries  of  the  glomeruli  and  of 
the  connective  tissue  interstices  of  the  cortex. 

In  this  case  the  infection,  doubtless,  originates  from  that  region  of 
the  skin  appertaining  to  the  left  inguinal  group  of 
lymphatic  glands.  At  this  side  the  deep-seated  inguinal 
lymphatic  glands  in  the  region  of  the  interior  crural  ring  are  con- 
siderably altered,  there  are  copious  haemorrhages,  especially  in  the  wall 
of  the  large  veins,  and  there  is  also  the  typical  gelatinous  yellowish 
oedema. 

Microscopically  the  liver  and  kidneys  exhibit  distinct  signs  of 
degeneration ;  the  spleen  is  acutely  swollen.  Excepting  those  haemor- 
rhages in  the  region  of  the  primary  bubo  no  others  are  discoverable. 

The  microscopical  examination  exhibits  the  enlargement  of  a 
superficial  inguinal  lymphatic  gland  principally  induced  by  enormous 
bacillary  infiltration  and,  in  a  far  less  degree,  by  the  increase  of  the 
polynuclear  leucocytes  and  by  haemorrhages. 

The  swelling  of  the  lymphatic  apparatus  at  the  neck  is  caused  by 
being  swamped  by  plague  bacilli.  They  are  present  in  the  lumens  of 
the  vessels  and  are  frequently  demonstrable  in  their  endothelial  cells. 
Whereas,  therefore,  we  first  of  all  observe  intensely  active  hyperaemia 
in  the  fresh  metastatic  glands  infected  through  the  circulation,  we  also 
find  increase  of  the  polynuclear  leucocytes  in  the  dilated  sinus,  and 
germinal  centres,  and  a  remarkable  swelling  of  the  lymphatic  endothelia 
and  the  cells  of  the  sinus,  with  swelling  and  lobulation  of  their  nuclei. 

The  acute  splenic  tumour  is  caused  by  hyperaemia,  enormous  infil- 
tration of  bacilli  and  leucocytes  permeating  the  organ  evenly,  and 
proliferation  of  the  endothelium  of  the  pulp  cavity. 

Extensive  fatty  degeneration  is  found  in  the  kidney,  especially  in 
the  epithelia  of  the  tubuli  contorti ;  this  is  sometimes  increased  to 
complete  nuclear  atrophy.  The  glomeruli  are  large,  often  quite  full  of 
blood ;  there  are  isolated  haemorrhages  in  the  interstitial  tissue. 
Plague  bacilli  are  discernible  everywhere  in  the  capillaries. 


246  Phif/Hc  in  the  Individual  [part  hi 

Bacteriologically,  the  case  is  proved  to  be  one  of  pure  plague 
infection. 

Cliinese.  "  An  adult  male,  aet.  25,  brought  to  the  public  mortuary  for 
examination'.  The  body  was  found  in  a  deserted  house.  The  corpse 
was  that  of  a  well-nourished  man.  The  skin  had  the  cyanosed  appear- 
ance met  with  in  plague.  On  superficial  examination  the  case  looked 
like  one  of  small-pox,  vesicles  and  pustules  being  scattered  over  the  face, 
shoulders,  arras,  body,  and  legs.  The  caretaker  of  the  mortuary,  who 
has  had  a  large  experience,  pointed  out  the  case  as  one  of  small-pox. 
An  eruption  covered  the  skin.  Papules,  vesicles,  and  pustules  were 
present  side  by  side.  They  were  numerous  over  the  neck,  back, 
shoulders,  back  of  arms,  ventral  surface  of  the  abdomen,  the  extensor 
surfiices  of  the  thigh  and  the  buttocks. 

"The  papules  were  fewest  in  number.  They  were  small,  never  larger 
than  a  pea,  raised  above  the  general  surface  of  the  skin,  and  surrounded 
by  extravasated  blood. 

"  The  vesicles  varied  in  size,  they  were  occasionally  umbilicated, 
apparently  ran  together,  contained  turbid  serum  containing  a  few  plague 
bacilli  and  were  also  surrounded  by  a  discoloured  area  of  skin  due  to 
blood  extravasation.  The  pustules  were  the  most  numerous.  They  also 
varied  much  in  size.  One  was  present  on  the  shoulder  which  resembled 
an  ordinary  boil.  Their  bacteriological  contents  were  subject  to 
considerable  variation.  Plague  bacilli  were  found  in  what  appeared  to 
be  the  most  recently  formed  pustules.  In  others,  which  were  evidently 
more  advanced,  no  plague  bacilli  were  found,  ordinary  pyogenic  micro- 
organisms being  present.     There  was  no  question  of  small-pox. 

"  A  bubo  was  present  in  the  right  groin,  which  contained  plague 
bacilli. 

"  Plague  bacilli  were  also  found  in  the  heart  blood  and  spleen. 

"  This  case  was  interesting  from  several  points  of  view,  namely : — 
1.     The  bubonic  nature  of  the  case. 
2      The  presence  of  a  generalised  skin  eruption. 

3.  The   nature    of  the   eruption    being  papular,    vesicular,   and 
pustular. 

4.  The  presence  of  the  B.  pestis  in  the  erupted  foci. 

5.  The  absence  of  an}'  apparent  lymphatic  connection  between 
the  eruption  and  the  bubo. 

6.  The  likeness  presented  by  the  case  to  small-pox." 

^  A  Risearch  into  Epidemic  and  Epizootic  Pldiinc.  By  William  Hunter,  Government 
Bacteriologist,  Hongkong,  1'.I04. 


CH.  xii]  Aiito^mes  247 

The  following  are  brief  notes  of  some  post-mortems,  made  for 
diagnostic  purposes,  on  persons  who  died  during  prevalence  of  plague. 

Indian,  male.  Large  bubo  in  right  groin,  skin  over  bubo  plum 
colour;  on  section  gland  shows  dirty  yellowish  colour  with  fleshy 
patches  and  haemorrhagic  streaks.  Glands  embedded  in  haemorrhagic 
clots  and  oedema.      Plague  bacilli  y)resent. 

Malay,  male.  Right  inguinal  bubo  (leg  flexed  and  abducted  on 
post-mortem  table).  Much  oedema  of  subcutaneous  tissue  in  region  of 
groin.  This  extends  up  on  the  anterior  abdominal  wall  for  about 
3  inches.  The  subcutaneous  fat  is  marked  with  petechiae.  Glands 
large,  dark  brown  in  colour,  and  surrounded  with  blood-stained  oedema. 
Smears  swarming  with  typical  bacilli. 

European,  male.  Glands  in  groin  not  enlarged.  No  bacilli.  Right 
lung  adherent  slightly ;  lower  part  of  upper  and  all  lower  lobe  in  a  state 
of  grey  hepatisation,  very  friable.  On  section  dirty  brown  fluid  poured 
out ;  air  had  been  entering  to  some  extent  the  affected  portion ; 
there  was  some  gelatinous  exudation  between  the  lower  part  of  lung 
and  diaphragm.  Smears  contain  B.  j)estis.  The  immediate  cause  of 
death  was  a  large  ante-mortem  clot  in  left  side  of  heart. 

Malay,  female.  Glands  in  right  femoral  and  inguinal  region 
enlarged,  very  dark  in  colour.  Smears  from  same  contain  many 
typical  bacilli.  Lungs  large,  pneumonic  (early  stage)  portions  in 
both  bases,  B.  pestis  in  smears.  Spleen  large,  very  soft.  Kidneys 
soft  and  congested.  Suprarenal  glands  dark  in  colour  and  congested 
around. 

Coloured,  female.  Femoral  and  inguinal  glands  on  right  side 
are  much  enlarged,  the  inguinal  being  congested  and  haemorrhagic. 
No  organisms  found  in  the  glands  on  microscopic  examination.  There 
had  been  great  haemorrhage  from  the  nose  and  mouth  just  previous  to 
death.  Lungs  pneumonic,  several  patches  and  full  of  blood.  B.  pestis 
present  in  the  pneumonic  patches.  Liver  cirrhotic,  spleen  large,  but 
no  bacilli  present. 

European,  female.  There  is  a  mark  purple  in  colour,  like  a  bruise, 
over  left  femoral  region,  a  distinct  swelling  being  noticed,  soft  and 
boggy  to  the  touch,  no  enlarged  gland  can  be  exactly  made  out. 
On  section  it  is  seen  that  much  haemorrhage  has  taken  place  into 
the  subcutaneous  and  intermuscular  tissue,  the  glands  are  much 
enlarged  and  soft,  almost  black  in  colour  and  completely  surrounded  by 
extravasated  blood.  Smears  made  from  glands  and  blood  sui'i-ounding 
them  swarm  with  B.  pentis. 


248  Plagiic  In  the  Tndlvifhial  [part  hi 

Greek,  male.  Glands  in  groins  small,  pink,  not  haeniorrhagic. 
Pericardium  filled  with  clear  yellow  fluid,  a  few  petechiae  on  outer 
surface.  Base  and  lower  lobe  of  left  lung  quite  solid,  pleura  tense,  on 
section  a  dark,  thick,  blood-stained  and  prune-juice  fluid,  sticky  in 
character,  exudes.  The  suifac-e  of  the  section  mottled  and  streaked 
with  haemorrhages  much  like  gland.  No  pleurisy.  Right  lung  also 
pneumonic  and  solid.     Tyjiical  B.  pestis  present  in  great  numbers. 

Malay,  feinale.  Glands  in  left  groin  enlarged ;  upper  half  of 
largest  gland  deep  red-brown  in  colour,  the  lower  part  only  pink. 
Much  oedema  around  the  glands,  the  oedema  extending  for  about 
3  inches  on  to  the  abdominal  wall  on  the  left  side.  B.  pedis  present 
in  great  nundiers  in  smears  from  glands  and  spleen. 


CHAPTER   XIII. 

CHANNELS   OF   INFECTION. 

It  is  a  well-known  flict  that  the  glands  draining  a  pigmented  or 

tattooed  cutaneous  area  are  blackish  in  colour.     It  is  in  view  of  this 

Infection  fad,  and  of  the  further  fixct  that  microbes  which  gain  access 

through  the        ^q  ^}^q   lymph  channels  throusrh   the   skin  are  obstructed 

skin  direct  to."^^  n     i       i  -i      no  ^ 

the  lymph-         m  the  nearest  groups  of  glands  and  affect  them  by  their 

**^°^'  pathogenic  action,  that  the  occurrence  of  primary  buboes  in 

the  inguinal  and  axillary  regions  in  most  cases  of  plague  has  given  rise 
to  the  conception  that  the  most  frequent  mode  of  entrance  of  the  in- 
fection is  through  the  skin  direct  to  the  lymphatics.  According  to 
this  view  the  plague  microbe,  having  reached  the  lymphatic  vessels 
distributed  in  the  skin,  is  conveyed  by  them  to  the  lymph  glands, 
which,  becoming  affected,  form  the  buboes  in  question.  At  this  stage 
no  bacilli  are  to  be  detected  in  the  blood  in  the  majority  of  cases,  and 
it  is  m^t  until  a  direct  communicaticm  is  opened  between  the  infected 
glands  of  the  bubo  and  the  walls  of  the  adjoining  veins,  by  the  coagu- 
lative  and  necrotic  action  on  the  tissues  by  the  plague  microbe  and  its 
toxines  contained  in  the  bubo,  that  there  is  an  entrance  of  bacilli  in 
great  numbers  into  the  general  circulation.  The  entrance  of  the  bacilli 
into  the  blood  in  septicaemic  cases  is  explained  by  the  weak  screen 
which  the  lymphatic  glands  are  able  to  furnish  against  the  penetrative 
energy  of  a  virulent  microbe.  The  explanation  is  not  a  very  satisfactory 
one.  The  limitation  which  narrows  down  the  entrance  of  the  microbes 
to  the  vascular  system  by  the  path  of  the  lymphatic  vessels  is  of  too 
restrictive  a  nature,  even  when  the  infection  has  taken  place  through 
the  skin. 

The  anatomical  distribution  of  the  superficial  lymphatics  with  their 
collecting  trunks  converging  to  the  inguinal  and  axillary  regions  cer- 
tainly affords  ffxcilities  for  the  absorption  of  the  infection,  in  the  case 


250  Plmjue  in  the  Jndividual  [part  iii 

of  an  accidental  wound  of  the  skin,  if  the  infection  docs  not  ])ass  direct 

into  the  blood  stream. 

Instances   occur  in   nearly  every  epidemic   in  which    medical    men 

Post-mortem       contract  plague  through  a  wound  or  abrasion  in  their  hand 

wounds.  which  has  been  infected  while  performing  a  post-mortem 

on  a  plague  case.     Aoyama  in  Hongkong  in  1894,  Sticker  in  Bombay 

in  1898,  Evans  in  Calcutta  in    1899,  and   Pestana  in  Oporto  in  1900, 

mav  be   mentioned   among    the   man}-  that    have    become    infected   in 

this  way.     In   such   cases   the   first   visible   sign   of  disease   is  usually 

an  axillary  bubo,  the  plague  bacillus  having  found  its  way  to  the  group 

of  glands  draining  the  area  sul)jected  to  the  inoculation.     Sometimes 

there    are   clear   signs   of  lymphangitis   proceeding   from    the    seat    of 

inoculation  to  the  affected  glands,  sometimes  there  is  a  vesicle  at  the 

site    of  infection   without    any  further   local    reaction,  as    in    Sticker's 

case,  while  at  times  there  is  no  positive  evidence  to  be  gathered  by  any 

visible  local  reaction  as  to  the  exact  site  of  the  entrance  of  the  plague 

bacilli,  although    that    site    is    known    from    the    circumstance    of  the 

wound.     Aoyama,  who  scratched  his  left  hand  at  one  post-mortem,  and 

his  right   hand  at  another  post-mortem  four  days  after,  suffered  from 

a  bubo  in  the  left  axilla  without  lymphangitis,  and  with  a  well-marked 

lymphangitis  on  the  right  arm.     This  power  of  the  bacillus  to  enter  the 

..^        system  throug-h  a  small   lesion  in  the  skin  without  pro- 
Power  of  the        -^  *  .  .  ^    . 

baciUus  to  ducing  a  local  reaction  at  the  seat  of  the  inocvdation  is 

tein  thro^uth^      noteworthy,  for,  apart   from  accidental  woundings  of  the 

a  small  lesion     skin  at  post-mortems,  the  seat  of  inoculation  in  natural 
in  the  skin  .    „       .  •         i  i  i  i  ,  _    ,      ,        . 

without  pro-       miections  is  seldom  traceable,  not  more  than  5  /„  showing 

ducing  a  local     .^■^,,  visible  siffns  of  the  infection  having  entered  through 
reaction  at  •'  o  .  .  °  ° 

site  of  inocu-      a  wound.     So  remarkable  is  this  fact  that  there  are  some 

physicians  who  hold  the  opinion  that  the  skin  is  not  the 

most  frequent  channel  of  infection,  but  that  the  bacillus  is  taken  into  the 

lungs,  or  alimentary  canal,  enters  the  general  circulation  and  multiplies 

in  the  blood,  or  selects  the  glands  in  the  groin,  arm-pit,  or  neck  for  its 

multijjlication.     Small-pox  can,  like  plague,  be  produced  by  inoculation, 

but  it  is  contended,  and  reasonably  so,  that  inoculation  of  the  small-pox 

virus  is  not  the  most  frequent  mode  by  which  the  natural  small-pox 

gains  an  entrance  into  the  human  system.     In  plague  there  may  be  an 

eruption  of  vesicles  which  contain  plague  bacilli  over  different  parts  of 

the  body,  which  can  only  be  considered  as  a  manifestation  of  a  general 

disease    and    not   as   a    local    infection.      Phlyctenules    of  a   vesicular, 

pustular,   carbuncular,    or    furuncular    nature    are    occasionally    to    be 


CH.  xiii]  Channels  of  Infection  251 

observed  on  the  hand  or  arm  when  there  are  axillary  buboes,  and  on 
the  foot  or  leg  in  inguinal  buboes ;  but  on  the  whole  the  appearance  of 
such  or  of  other  signs  is  rare.  The  phlyctenules  contain  plague  bacilli, 
and  are  usually  ascribed  to  the  bite  or  sting  of  an  infected  insect. 

There  are  now  a  number  of  cases  recorded  of  direct  infection  caused 
by  the  bite  of  a  plague-stricken  rat.  A  case  of  infection  by  the  bite  of 
a  sick  rat  is  reported  by  Dr  Francis  Clark,  the  Medical  Officer  of  Health 
foi-  Hongkong.  A  man  employed  as  a  turncock  was  bitten  on  the  left 
thumb  and  some  two  or  three  days  later  the  arm  became  swollen  and 
painful.  The  man  died  in  some  9  or  10  days,  his  illness  not  being 
reported.  On  post-mortem  examination  two  small  wounds  were  found 
on  the  ball  of  the  left  thumb,  the  left  hand  and  fore-arm  were  much 
swollen,  and  in  the  left  axilla  there  was  a  brawny,  oedematous  swelling, 
in  the  midst  of  which  was  an  enlarged  haemorrhagic  gland ;  a  smear 
preparation  from  this  gland  showed  numerous  typical  plague  bacilli  ^ 

It  has  been  observed  that  disinfectors  and  others  exposed  to  the 
infection  appear  to  be  less  liable  to  be  attacked  when  wearing  boots. 
The  explanation  of  this  may  be  that  the  boots  protect  the  feet  which  have 
lesions  on  them  from  coming  in  contact  with  infectious  material,  or  that 
they  protect  them  from  the  bites  of  infected  insects.  The  experiments 
already  referred  to  in  another  part  of  this  work  show  that  infected  fleas 
are  capable  of  infecting  healthy  rats  and  possibly  monkeys  with  plague, 
that  these  same  fleas  will  attack  man  when  they  are  hungry,  and  it  is 
reasonable  to  suppose  that  their  capacity  to  cause  plague  in  animals 
extends  to  man.  It  has  also  been  observed  that  oilmen  appear  to  enjoy 
exceptional  immunity  from  plague,  which  has  been  attributed  to  the 
protection  afforded  by  the  oil  to  the  skin.  It  used  to  be  a  common 
practice  for  oil  to  be  employed  as  a  protective  against  plague. 

Sometimes  a  prick  or  scratch  with  an  infected  instrument  may 
Infection  introduce  the  infection  direct  into  the  blood  vessels  of  the 

through  the  part  and  thence  into  the  circulation,  and  then  the  bacilli 
to  the  blood  ^i^a-Y  lodge  in  a  group  of  glands  more  remote  than  that 
vessels.  receiving  the  lymph  from  the  wounded  part.     For  instance 

at  Oporto  in  1900  Professor  Levi  of  Stockholm  had  the  front  part  of  his 
left  fore-arm  accidentally  scratched  by  an  infected  knife  while  he  was 
performing  a  post-mortem.  The  wound  was  immediately  washed  and 
bathed  with  a  solution  of  sublimate  and  lysol.  In  40  hours  a  sudden 
pain  was  felt  in  the  left  groin  together  with  general  malaise,  and  in 

'  "A  Report  of  the  Epidemic  of  Bubonic  Plague  in  Hongkong  for  the  year  1900."   By  the 
Medical  Officer  of  Health  for  the  Colony. 


252  Plague  in  the  Individual  [part  hi 

8  hours  a  femoral  bubo  developed  at  the  seat  of  pain.  In  this  case 
there  was  no  screening  or  arrest  of  the  bacilli  until  they  reached  the 
inguinal  region,  and  the  route  by  which  they  arrived  at  this  group  of 
glands  could  not  have  been  through  the  lymphatic  system.  The  selection 
of  the  inguinal  region  for  the  bubo  when  the  infection  entered  the  system 
through  the  skin  of  the  fore-arm  is  noteworthy.  A  similar  direct  blood 
infection  may  take  place  when  the  inoculation  of  the  bacillus  is  effected 
by  the  bite  of  an  infected  insect.  It  is  possible  also  for  a  blood  infection 
to  occur  by  the  direct  connection  which  sometimes  exists  anatomically 
between  the  lymphatic  vessels  and  veins,  and  occasionally  arteries  in  the 
thoracic,  axillary  and  inguinal  region.  These  direct  connections  between 
the  lymphatic  and  circulatory  systems  have  been  shown  by  Dr  Leaf 
to  exist'.  He  points  out  that  some  of  the  smaller  arteries  in  the  thoracic 
region  open  directly  into  lymphatic  trunks ;  that  direct  communications 
are  found  to  exist  between  arteries,  lymphatic  vessels  and  veins  in  many 
regions  of  the  body ;  and  that  the  portal,  axillary,  internal  iliac,  and  the 
azygos  veins  all  directly  communicate  with  the  lymphatic  system.  It 
is  evident  that  if,  under  these  conditions,  one  of  the  systems  becomes 
infected,  there  is  an  opportunity  of  the  infection  spreading  to  the  other 
system,  and  it  is  by  no  means  a  sine  quel  non  that  the  blood  stream  is 
only  infected  after  the  lymph  glands  in  the  bubo  have  broken  down, 
even  in  those  cases  when  the  infection  travels  along  the  lymph 
channels. 

The  frequency  of  septicaemic  cases,  amounting  in  some  epidemics  to 
at  least  50  and  60^0  c>f  the  cases,  indicates  that  the  plague  bacillus  can 
obtain  ready  access  to  the  blood,  and  this  without  any  greater  injury  to 
the  glands  in  the  inguinal  or  axillary  regions  than  that  to  other  lymph 
glands  in  the  body.  The  similar  condition  of  all  the  lymph  glands  of  the 
body  points  to  some  other  entrance  of  the  bacillus  into  the  system  than 
through  the  inguinal  or  axillary  glands. 

That  infection  can  and  often  does  take  place  through  the  skin  there 
is  no  manner  of  doubt,  but  when  this  mode  of  infection  occurs  it  is  not 
established  that  the  i)lague  bacillus  reaches  the  inguinal  or  axillary 
regions  only  by  the  lymph  channels.  It  is  not  even  established  that  the 
skin  is  the  most  frequent  channel  of  infection. 

The  preponderance  of  inguinal  buboes  among  people  with  bare  feet 
was  held  at  one  time  to  be  proof  of  infection  through  the  skin  of  the 
feet.     Among  people  that  go  about  barefooted  cracks  and  abrasions  on 

1  "  On  the  Relation  of  Blood  to  Lymphatic  Vessels."     By  C.  H.  Leaf,  M.B.     Lancet, 
March  3rd,  1900. 


CH.  xiii]  Channels  of  Infection  253 

the  feet  are  common,  and  this  fact  was  used  as  an  argument  in  support 
of  this  mode  of  infection.  But  the  same  preponderance  of  inguinal 
buboes  occurs  among  Europeans  when  booted,  and  in  most  epidemics,  in 
whatever  part  of  the  world  they  may  occur,  inguinal  buboes  are  the 
most  frequent.  Further,  in  cases  of  primary  bubo  of  the  inguinal  or 
axillary  region,  the  bubo  is  not  always  the  first  symptom  of  illness. 
There  may  be  shivering,  fever,  prostration,  and  general  illness  for  a  day 
or  several  days  before  there  is  any  appearance  of  a  bubo.  The  order  of 
symptoms  is  such  as  to  be  suggestive  that  during  the  period  of  incuba- 
tion and  earlier  stage  of  the  disease  the  bacillus  is  already  in  some  part 
of  the  vascular  system,  and  only  later  selects  the  group  of  glands  for  its 
bubonic  manifestations.  It  is  possible  that  in  some  cases  in  which  the 
buboes  appear  to  be  the  first  manifestation,  infection  of  the  inguinal 
or  axillary  glands  also  takes  place  from  the  blood,  these  groups  of 
glands  possessing  a  selective  power  for  the  plague  bacilli  in  the  blood. 
This  view  has  certain  facts  in  its  support.  Plague  microbes  have  been 
found  in  the  blood  in  mild  types  of  the  disease  when  large  quantities  of 
blood  have  been  employed  for  the  examination.  They  have  also  been 
found  in  the  blood,  so  far  as  Hongkong  is  concerned,  in  every  variety  of 
the  disease  there.  The  detection  of  the  bacilli  was  made  by  taking 
thick  films  of  blood,  washing  out  their  haemoglobin,  and  then  staining. 
The  method  is  the  same  as  that  adopted  by  Ross  for  detecting  the 
malarial  organism.  By  this  method  plague  bacilli  have  been  discovered 
in  the  blood  before  the  onset  of  the  fever  or  the  appearance  of  buboes, 
during  the  progress  of  the  disease  and  during  convalescence. 

The  fact  of  the  bubo  frequently  making  its  appearance  several 
Older  view  is  days  after  the  onset  of  the  illness  favours  the  view  just 
that  plague  enunciated,  and  which  was  held  by  older  writers,  viz.  that 
disease,  and       plague  is  primarily  a  general  disease,  and  that  the  affection 

that  the  bu-  ^f  ^|^^,  glands,  internal  or  external,  with  the  eruption  of 
boes  are  its  .  .  .  . 

local  mani-         the  bubo  or  buboes,  is  a  local  manifestation  of  the  disease 

similar  to  that  which  appears  in  the  skin  eruption  in 
small-pox,  scarlet  fever,  and  measles.  It  is  based  on  the  general  ex- 
perience that  the  glands  in  all  cases  of  plague  are  more  or  less  affected. 
This  view  is  contrary  to  that  commonly  accepted  to-day,  which  considers 
the  bubo  to  be  the  primary  local  lesion,  the  toxines  from  which  become 
absorbed  and  give  rise  to  the  general  symptoms.  The  whole  question 
still  appears  to  be  a  moot  point  and  is  by  no  means  yet  settled. 
Neither  view  adopted  exclusively  explains  the  different  types  of  ])lague. 
In  the  early  days   of  the  Bombay  epidemic   when  the   latter  theory 


2o4  Plague  in  the  Individtial  [part  hi 

was  formulated,  it  was  a   rare  occurrence  to  detect  plague  bacilli  in 

bubonic   cases    except   a   short   time    before   death,  but    now   at    least 

45  7o  of  the  cases  received  into  hospital  contain  plague  bacilli  in  their 

blood.     The    latter    percentage    more    nearly   approaches    the    results 

obtained  by  Kitasato,  Wilm,   and   others  in  Hongkong,  where   in  the 

epidemic  of  1894  and  the  recurring  outbreaks  since  then  plague  bacilli 

have  been  found  in  the  blood  in  more  than  80  Vo  of  the  cases.     It  is 

evident  that  plague  may  differ  in  its  character  at  different  times  in  one 

locality  as  well  as  in  different  localities,  and  that  the  absence  or  presence 

of  certain    characteristics    in    an    epidemic   does  not  justify  denial   or 

positive  assurance  of  their   existence  in  another.     At  the  same  time 

that  which  appears  obvious  in  one  epidemic  may  receive  considerable 

modification   when    viewed   from   the   experience   derived   in   another 

epidemic. 

Inoculation    through    the  mucous    membrane    is   another   mode    of 

infection.     The  mucous  membrane  is  more  liable  than  the 

through  the       skin  to  slight  abrasions,  and  the  passage  of  infected  food 

mucous  over  its  surface  probably  subjects  it  to  a  more   fi'equent 

membrane.  .  .  . 

exposure  to  the  risk  of  infection  than  even  any  part  of  the 

skin.     Not    infrequent    channels  of    infection  are   the  mouth  and   the 

tonsils,  giving  ri.se   respectively   to  submaxillary  and  cervical   buboes; 

this  has  often  been  proved  experimentally.    Monkeys,  pigs,  calves,  sheep, 

rats,  hens,  ducks,  geese  and  pigeons  contract  plague  by  feeding  on  food 

which  has  previously  been  infected.    The  monkey  is  the  nearest  approach 

to    man    of  the    animals    experimented    on,    and    plague-infected    food 

certainly  gives  plague  to  the  monkey.     The  plague  is  often  of  a  septi- 

caemic  type  with  no  particular  enlargement  of  the  glands  of  the  neck, 

while  sometimes  there  is  a  very  distinct  affection  of  the  tonsils  and 

glands  of  the  neck.     The  facility  with  which  the  lower  animals  contract 

plague  by  feeding  is  in  fiivour  of  man  contracting  it  often  in  the  same 

way.     In    Hongkong  the    mesenteric    glands    were    often   swollen    and 

extravasated  and  the  condition  of  the  stomach  was  very  haemorrhagic ; 

the  morbid  appearances  seemed  to  point  to  a  primary  infection  of  the 

glands,  but  in  those  cases  in  which  the  glands  were  not  specially  affected 

the  fact  does  not  exclude  infection  from  the  alimentary  canal,  in  that  if 

it  is  admitted  that  a  septicaemic  case  of  plague  may  be  caused  by  an 

infection  through  the  skin  without  any  primary  buboes  or  any  visible 

sign  of  solution  of  continuity  the  same  conditions  may  apply   to   the 

infection  passing  through  an  intact  mucous  membrane.     Plague  bacilli 

placed  on  the  mucous  membrane  of  the  nostrils  and  tonsils  will  pass 


CH.  xiii]  Channels  of  Infection  255 

through  these  membranes  although  there  may  be  no  lesion.  The 
situation  of  the  blood  vessels  above  the  lymphatic  network  in  the 
alimentary  canal  may  allow  of  the  direct  entrance  of  the  bacillus  into 
the  circulation.  On  deducting  these  cases  in  which  the  cervical  glands 
appeared  to  be  primarily  infected  the  usual  type  of  })lague  caused  by 
feeding  animals  with  plague  material  was  the  septicaemic.  On  the 
other  hand  it  is  necessary  to  point  out  that  in  Natal,  where  plague  has 
never  reached  epidemic  proportions,  experiments  by  feeding  carried  out 
after  the  plague  season  failed  to  produce  plague  in  animals'. 

The  presence  of  plague  bacilli  in  the  intestinal  contents,  mucus  of 
the  mouth  and  urine,  of  about  one-third  of  the  rats  infected  with  plague 
subjects  the  food  which  may  be  exposed  over-night  in  an  infected  house 
to  considerable  risk  of  contamination.  With  food  that  has  still  to  be 
cooked  the  danger  is  small,  but  with  food  that  has  already  been  cooked 
and  which  will  be  eaten  cold  the  danger  of  infection  is  great.  It  is 
of  small  importance  what  part  of  the  alimentary  canal  takes  up  the 
infection. 

In  Hongkong  plague-infected  fowls  were  discovered  in  the  markets, 
and  it  was  pointed  out  by  Dr  Atkinson,  the  Principal  Medical 
Officer  of  Health  of  Hongkong,  that  it  is  the  custom  of  many  of  the 
Chinese  to  use  the  uncooked  entrails  of  fowls  as  a  sort  of  relish,  and  to 
eat  fowls  only  half-cooked,  preferring  them  in  this  condition.  Under 
these  circumstances  the  danger  attendant  on  eating  plague-infected 
poultry  is  a  real  one.  In  1903  Dr  Hunter  discovered  plague  bacilli 
in  two  samples  of  rice  taken  from  a  house  in  Hongkong. 

Cervical  buboes  may  be  caused  by  infection  derived  from  the  skin,  or 
from  the  mouth,  or  tonsils,  or  nostrils.  Buboes  in  the  cervical  region  in 
Chinese  patients  have  been  traced  to  mothers  sucking  the  open  buboes 
of  their  children.  Unless  there  is  a  clear  history  it  may  be  difficult  to 
say  from  the  appearance  of  the  tonsils  and  pharynx  which  is  the  source 
of  infection,  because  these  often  become  affected  by  extension  of  the 
yjathological  changes  from  the  cervical  glands.  Similar  inflammatory 
and  diphtheritic  appearances  may  sometimes  be  seen  in  the  tonsils  in 
cases  in  which  the  infection  has  obtained  access  to  the  blood  and  when 
the  buboes  are  inguinal  or  axillary.  Plague  bacilli  may  be  found  in  the 
sputum  whenever  the  tonsils  and  pharynx  are  much  affected,  whether 
due  to  a  local  infection,  or  to  an  extension  from  the  cervical  glands,  or 
to  a  general  infection. 

1  Report  oil  the  Phujue  in  Natal,  1902-3.  By  Ernest  Hill,  Health  Officer  for  the 
Colony. 


•2.')0  Plague  in  the  fndundaal  [part  hi 

In  1 897  a  Bombay  nurse  at  the  Parel  Hospital  received  in  the  eye  a 
particle  of  sputum  coughed  up  by  a  patient  suffering  from  pneumonic 
plague.  Although  the  parts  were  carefully  washed  conjunctivitis  set  in 
the  next  day,  which  was  followed  by  a  swelling  of  the  parotid,  a  bubo 
below  the  ear  on  the  affected  side,  and  death.  A  similar  case  occurred 
in  Hongkong. 

Another  mode  of  infection  is  by  the  respiratory  tract.  The  local 
infection  of  nostrils,  pharynx,  or  mouth  may  extend  into 
througiTthe  ^^e  lungs  and  set  up  the  pneumonic  form  of  plague,  or  the 
respiratory  bacillus  may  gain  an  entrance  direct  into  the  lungs  by  the 
inspiration  of  infected  material  producing  bronchitis  and 
pneumonia.  In  the  latter  mode  of  infection  there  is  no  primary  bubo 
of  the  neck.  There  is  no  cervical  bubo  when  the  broncho-pneumonia 
of  plague  is  experimentally  caused  by  the  intratracheal  injection  of 
cultures  of  the  plague  bacillus.  Pneumonic  plague  has  also  followed 
subcutaneous  injection  of  animals  with  plague  material  from  pneumonic 
plague,  so  that  it  is  apparent  that  primary  plague  pneumonia  may  be 
produced  in  some  cases  by  the  plague  bacillus  entering  the  lungs  from 
the  general  circulation.  It  appears  to  be  a  case  of  selection  of  the 
lungs  instead  of  the  glands  of  the  groin,  arm-pit,  or  neck.  In  this 
connection  some  of  the  cases  of  plague  caused  by  post-mortem  wounds 
have  resulted  in  plague  pneumonia,  and  it  is  a  curious  fact  that  those 
cases  which  have  arisen  from  laboratory  infections,  and  which  are 
generally  attributed  to  direct  infection  from  animals  handled,  were  of 
a  pneumonic  type. 

The  secondary  pneumonia  of  plague  is  caused  by  an  infection  from 
Mixed  the  general  circulation   sequent   either  to  a   septicaemic 

infection.  ^,.^^^^  ,)j.  ^q  ^]^g  haemorrhagic  extravasation  of  a  bubo  into 

a  vein.  In  pneumonic  plague  the  specific  bacillus  is  often  associated 
with  the  diplococcus  pneumoniae,  which  may  in  some  pneumonic 
patches  be  exceedingly  numerous  and  in  greater  numbers  than  the 
plague  bacillus. 

Mixed  infections,  except  in  the  lung  when  the  diplococcus  pneumoniae 
is  associated  with  the  plague  microbe,  appear  to  be  generally  due  to  the 
entrance  into  the  blood  of  other  micro-organisms  through  the  ulcerated 
nmcous  membrane  of  the  mouth  and  tonsils. 

During  life  the  mode  of  exit  of  infection  will  depend  on  the  type  of 

the    disease  and    the    condition    of  the   patient.     In   the 
Mode  of  exit  ,.  •         i  •   i     ^i 

of  infection        bubonic  type  m  its  earlier  stages,  m  which  the  primary 

from  the  ^^^t^^   appears   to   be   the   result   of  the   plague  bacillus 


cii.  xiii]  Duration  of  Infectivity  257 

reaching  the  affected  glands  by  the  lymphatic  channels,  the  infective 
agent  is  limited  to  the  glandular  or  periglandular  tissue  and  only 
finds  an  exit  externally  when  the  bubo  suppurates.  At  the  stage 
of  suppuration  bacilli  are  often  not  to  be  found  in  the  pus,  and 
it  is  only  towards  the  periphery  of  the  necrosed  tissue  that  bacilli,  not 
infrequently  of  an  involuted  form,  may  be  discovered.  The  rounded 
forms  which  are  very  common  may  be  mistaken  for  micrococci,  and  the 
bladder-like  forms  are  apt  to  be  overlooked  because  of  their  not  staining 
well.  There  is,  however,  much  variation  in  both  the  number  of  bacilli 
and  the  duration  of  their  vitality  in  suppurating  buboes.  Generally 
the  bacilli  are  rapidly  destroyed,  and  few  or  even  none  may  be  left  to 
escape  to  contaminate  dressings  and  bed-clothes,  but  occasionally  they 
retain  their  vitality  for  a  long  period  and  remain  alive  so  long  as  any 
pus  or  necrosed  tissue  remains. 

In  cervical  buboes  in  consequence  of  the  involvement  of  the  mucous 
membrane  of  the  mouth  and  pharynx  and  of  the  tonsils,  plague  bacilli 
may  escape  by  the  mouth  in  the  sputum  and  saliva.  Similarly  bacilli 
may  appear  in  the  sputum  when  the  tonsils  or  glands  of  the  mouth  are 
primarily  infected.  As  boils,  vesicles,  pustules,  haemorrhages,  and  other 
eruptions  on  the  skin  which  occur  in  plague  usually  contain  plague 
bacilli,  any  detachment,  rupture  or  breach  of  the  epidermis  over  these 
will  allow  of  the  escape  of  plague  bacilli.  Should  the  bacilli  find  their 
way  in  considerable  numbers  from  the  primary  bubo  into  the  general 
circulation,  which  is  a  common  occurrence  a  short  time  before  death, 
then  the  avenues  of  exit  become  similar  to  those  of  a  plague  case  which 
is  septicaemic  from  the  commencement. 

In  a  septicaemic  case  all  the  secretions  and  excretions  except  the 
perspiration  may  contain  the  plague  microbe,  and  the  infectious  agent 
may  consequently  appear  in  the  sputum,  saliva,  urine,  and  faeces,  and  in 
haemorrhagic  discharges.  In  the  pneumonic  cases  there  are  usually 
enormous  numbers  of  bacilli  in  the  sputum.  In  the  dead  body  the 
bacillus  is  usually  in  all  the  fluids  of  the  system  and  will  escape  with 
any  sanguineous  discharges  that  may  dribble  from  the  cavities. 

Closely  connected  with  the  mode  of  exit  of  the  infective  agent  from 

the  body  is  the   duration  of  vitality  of  the    bacillus   in 
The  diiration  ,  .  ,     ,       .  .         ,  .  , 

of  the  infect-      convalescent  patients.     In  sniiple  bubonic  cases  in  which 

ivityofcoii-       there   is  no  secondary  pneumonia  or  other  complication, 
valescents.  .  -^    ^  ^ 

and  in  which  the  buboes  resolve  themselves  and  there  are 

no  bacilli  in  the  blood,  the  infectivity  is  practically  nil  and  need  not  be 

considered,  but  where  the  buboes  suppurate  the  duration  of  the  presence 

s.  17 


258  Plague  in  tlie  Individual  [part  hi 

of  the  bacillus  varies  so  much  that  no  set  time  can  be  placed  upon  it, 
and  the  only  method  of  ascertaining  freedom  of  infection  is  to  examine 
microscopically  and  make  cultures  of  the  pus.  In  cases  of  doubt  it  may 
be  advisable  to  inoculate  an  animal.  There  are  occasionally  cases  of 
indolent  buboes  with  late  suppuration,  and  in  these  the  vitality  of  the 
bacillus  may  be  prolonged  for  a  very  lengthened  period.  Thus  two 
cases  are  mentioned  by  Dr  Choksy  of  Bombay,  in  which  iliac^  buboes 
were  opened  through  the  abdominal  wall  on  the  48th  day  of  illness  and 
the  pus  was  found  to  contain  plague  bacilli  in  an  active  state  and 
capable  of  growth  when  cultured. 

Kitasato  isolated  plague  bacilli  from  the  blood  of  convalescents,  and 
this  observation  has  been  repeated  and  confirmed  in  Hongkong,  but 
it  is  not  determined  how  long  they  may  remain  in  the  system.  The 
Austrian  Connnission-  found  plague  bacilli  in  the  spleen  of  a  patient 
who  died  on  tlie  52nd  day,  which  points  to  the  possibility  of  a  patient 
retaining  the  infection  for  a  long  time. 

Dr  Gotschlich^  records  three  instances  of  convalescents  from  pneu- 
monic plague,  which  were  treated  in  the  hospital  at  Alexandria,  showing 
bacilli  of  a  virulent  type  in  their  sputum  for  considerable  periods  after 
they  were  apparently  well.  In  the  first  case  the  bacilli  retained  their 
virulency  to  the  76th  day  of  the  patient's  illness  and  the  42nd  day  after 
rising  from  his  bed.  In  the  second  case  the  bacilli  in  the  sputum  were 
virulent  on  the  35th  day  after  the  onset  of  the  disease,  and  6  days  after 
the  patient  had  so  far  recovered  as  to  leave  his  bed.  In  the  third  case 
the  bacilli  were  isolated  from  the  sputum  up  to  the  41st  day  from  the 
commencement  of  the  illness  and  19  days  after  the  patient  had  left  his  bed. 

The  importance  of  a  bacteriological  examination  of  the  sputum  is 
obvious  in  order  that  patients  shall  not  be  allowed  to  mix  with  healthy 
persons  while  they  are  still  in  an  infective  state,  and  that  due  pre- 
cautions shall  be  taken  to  disinfect  the  sputum  as  long  as  it  contains 
plague  bacilli.  This  question  of  the  duration  of  the  infectivity  of 
patients  who  have  been  ill  with  plague  requires  much  more  investiga- 
tion than  it  has  yet  received. 

The  best  mass  of  evidence  collected  on  the  length  of  the  incubation 
Incubation  period  of  plague  is  that  recorded  by  the  Indian  Plague 
period  of  Commission^     Information  regarding  71   cases  is  given, 

p  ague.  together  with  the  references  derived  from  the  records  of 

'  The  Treatment  of  Plague  with  Profexsor  Litstig's  Scrum.  By  N.  H.  Choksy,  M.D. 
1'.I0.S. 

-  H.  Albrecht  u.  A.  Ghon.     Ueher  die  Beulcnpest  in  Bombay  im  Jahrc  1897,  p.  532. 
='  Zeitschrijt  fiir  Hygiene  and  Infectionskrankheiteii,  1899,  xxxii.  p.  402. 
•*  Report  of  the  Indian  Plague  Commission,  Vol.  v.  cap.  iii.  p.  78. 


CH.  xni]  Inciibatlon  Period  259 

segregation  and  evacuation  camps.  The  cases  are  divided  into  three 
classes. 

Class  I.  Group  A,  cases  in  which  there  is  a  history  of  a  direct 
inoculation  of  infective  material,  and  Group  B,  cases  where  there  is 
a  history  of  the  patient  having  come  specially  into  contact  with 
infection  on  a  particular  occasion.  In  both  groups  there  were  cases  in 
which  the  incubation  period  could  not  have  been  longer  than  24  hours 
and  other  cases  in  which  it  extended  to  5  days.  The  average  length  of 
the  incubation  period  was  about  3  days. 

Class  II  consists  of  cases  in  which  there  is  a  history  of  the  patient 
having  been  in  contact  with  infection  on  and  after  a  particular  day. 
The  data  gathered  for  this  class  confirm  those  of  Class  I  in  placing  the 
period  of  incubation  between  one  and  five  days. 

Class  III  represents  cases  in  which  plague  developed  after  removal 
from  infected  surroundings.  Out  of  753  cases  noted,  15  or  1"9  7o> 
developed  plague  after  the  10th  day.  It  is  stated,  however,  that  these 
later  cases  may  have  contracted  the  infection  after  removal  to  camp. 

It  is  not  the  shortest  period  of  incubation  that  is  the  most  important 
for  preventive  measures,  except  it  be  a  question  as  to  whether  a  person 
exposed  to  the  infection  should  be  inoculated  and  the  possibility  or 
probability  of  the  disease  coming  on  before  the  prophylactic  has  had 
time  to  act.  The  extreme  limit  of  the  incubation  period  is  however  of 
the  greatest  consequence  as  forming  a  basis  for  practice  in  regard  to  the 
length  of  time  required  to  segregate  persons  who  have  been  exposed  to 
infection,  or  to  isolate  crowds  of  emigrants  or  coolies  from  an  infected 
country  before  their  admission  to  one  which  is  not  infected,  or  to 
declare  when  a  person  who  has  been  exposed  to  infection  is  safe  from 
attack.  In  the  vast  majority  of  cases  6  days  may  be  considered  to  be 
the  extreme  limit  of  the  incubation  period,  but  there  is  a  residuum  in 
which  10  days,  fixed  by  the  Venice  Convention,  are  needed  to  cover  the 
incubation  period.  There  are  very  exceptional  cases  in  which  the 
period  of  incubation  appears  to  have  extended  to  12  and  even  14  days. 
But  these  are  rareties  and,  except  when  dealing  with  emigrants  and 
coolies  in  large  numbers,  they  may  be  disregarded.  The  Paris  Con- 
vention of  1903  has  fixed  a  period  of  5  days  for  isolation  of  persons  from 
plague-infected  ships,  and  which  may  or  may  not  be  followed  by 
surveillance  of  not  more  than  5  days. 


17—2 


CHAPTER   XIV. 

CLINICAL  FEATURES. 

Plague  was  formerly  classified  according  to  the  mildness  or  severity 

of  the  disease  as    Pestis  Minor   and   Pestis   Major,   and 

classification      Pestis  Siderans  or   Pestis  Fulminans.     Pestis   Minor   in- 

or  types  of  eluded  cases  which  were  of  a  mild  character  and  ended  in 
plague. 

recovery.     Pestis  Major  comprised  the  more  severe  cases. 

Pestis  Siderans  or  Pestis  Fulminans  embraced  those  cases  that  were 
rapidly  or  suddenly  fatal.  Other  terms,  such  as  bubonic,  haemorrhagic, 
and  nervous,  were  employed  to  designate  the  more  prominent  features 
that  presented  themselves  in  particular  cases. 

The  classification  now  adopted  is  one  which  is  based  more  or  less  on 
the  particular  system  of  the  body  invaded  in  force  by  the  plague 
bacillus,  and  plague  is  divided  into  bubonic,  septicaemic,  and  pneu- 
monic, according  to  whether  the  glandular,  circulatory,  or  respiratory 
systems  are  mostly  involved.  Other  types,  such  as  cellulo-cutaneous 
or  carbuncular,  intestinal  and  cerebral,  have  been  described.  They  are 
applied  to  cases  in  which  some  symptom  or  symptoms  are  more  pro- 
nounced than  usual.  A  separate  classification  of  these  atypical  cases 
only  unnecessarily  complicates  matters  and  will  not  be  followed  here, 
though  it  should  be  mentioned  that  such  modification  of  symptoms 
has  to  be  borne  in  mind  from  a  diagnostic  point  of  view.  Even  the 
three  accepted  types  are  artificial  distinctions  useful  to  draw  attention 
to  the  different  garbs  in  which  the  disease  may  present  itself,  and  in 
the  case  of  the  pneumonic  variety,  which  is  highly  infective,  valuable 
from  an  administrative  point  of  view  in  that  it  is  desirable  the  cases 
should  be  immediately  isolated ;  but  they  are,  after  all,  only  different 
manifestations  or  degrees  of  the  same  disease  which  in  its  main  features 
has  a  common  likeness.     The  type  with  buboes  is  the  most  common, 


CH.  xiv]  Clinical  Features  261 

ranging  from  70  to  SO  per  cent,  of  the  cases.  Typical  cases  of  each 
variety  may  be  met  with  in  every  epidemic  but  they  very  fre(|uently  run 
into  one  another.  Thus  the  bubonic  form  may  become  septicaemic,  the 
septicaemic  may  develop  buboes  or  pneumonia,  and  the  pneumonic  may 
become  septicaemic  or  bubonic  or  both. 

The  disease  also  in  its  varying  types  may  range  from  a  mild  to  a 
severe  attack,  from  a  prolonged  illness  to  death  within  a  few  hours,  and 
it  may  have  many  of  its  symptoms  absent  or  run  an  irregular  course. 
The  cases  met  with  in  China  and  India  presented  very  considerable 
differences  from  those  in  South  Africa,  and  it  was  difficult  to  realise  at 
first  that  the  patients  were  suffering  from  the  same  disease.  The 
frequent  presence  of  great  mental  aberration  and  of  typhoid  symptoms 
in  the  former  contrasted  with  their  comparative  absence  in  the 
latter.  It  is  probably  variations  of  this  kind  which  lead  to  such 
different  observations  in  different  places,  as  regards  the  mode  of  in- 
fection, the  variation  in  types,  the  liability  of  animals  to  disease,  and  the 
degree  of  infectivity.  There  are  few  diseases  which  present  a  greater 
variety  of  manifestations. 

Plague  may,  for  descriptive  purposes,  be  broadly  classified  into 
plague  with  buboes  and  plague  without  buboes.  This 
and  without  distinction  is  only  a  clinical  one,  for  in  all  forms  of  plague 
the  lymphatic  glandular  system,  although  it  may  not  be 
detected  during  life,  is  found  in  post-mortems  to  be  more  or  less 
affected.  This  is  even  the  case  in  the  pneumonic  form.  Superadded 
to  the  symptoms  peculiar  to  the  several  varieties  of  plague,  such  as  the 
appearance  of  buboes  in  bubonic  plague  and  the  affection  of  the  lungs 
in  pneumonic  plague,  and  the  sudden  and  intense  prostration  in  septi- 
caemic plague,  there  are  certain  symptoms  in  plague  which  are  common 
to  every  variety.  They  are,  the  peculiar  expression  of  the  face,  the 
characteristic  appearance  of  the  tongue,  the  intoxication  or  perturbation 
of  the  nervous  system,  the  halting  speech,  the  staggering  gait,  and  the 
great  prostration.     These  will  be  referred  to  later  on. 

The  incubation  period  of  whatever  type  the  disease  may  be  varies 
generally  between  a  few  hours  and  five  days,  it  being 
p°riod*^°°  rarely  longer.  Cases  have  been  recorded  with  longer 
periods,  but  it  is  often  difficult  to  dissociate  froin  them 
the  possible  exposure  to  infected  clothes  or  infected  animals  at  a  date 
later  than  that  which  is  believed  to  be  the  time  of  infection.  Still  the 
evidence  at  present  existing  does  not  exclude  the  possibility  of  the 
period  of  incubation  being  prolonged  occasionally  to  12  or  14  days. 


262  Plague  in  the  Imliridnrd  [part  tit 

Promunitory  syiiiptoviis  are  seldom  observed.  They,  however, 
Premonitory  occur  in  some  cases  and  more  in  some  epidemics  than  in 
symptoms.  others.     They  usually  consist  in  loss  of  appetite,  languor, 

low  spirits,  frontal  headache,  furred  tongue  with  red  tip  and  edges, 
nausea,  vomiting,  diarrhoea,  giddiness,  weakness  in  the  limbs,  and  pains 
in  the  loins.  These  may  continue  for  one  or  two  days  when  the  period 
of  invasion  sets  in,  the  symptoms  of  which  vary  according  to  the  severit}' 
of  the  attack.  Perhaps  the  most  remarkable  characteristic  in  con- 
nection with  plague  is  the  difference  in  the  onset  and  progress  of  the 
disease  in  different  cases.  On  the  one  hand  no  disease  except  cholera 
manifests  in  its  severer  forms  so  rapid  a  development  of  its  symptoms 
and  overwhelms  or  prostrates  the  patient  to  the  verge  of  death  in  so 
short  a  time.     On  the  other  hand  it  may  take  a  most  leisurely  course. 

In  the  mild  variety  of  the  bubonic  form,  which  corresponds  to  the 

^   ^    .  Pestis  minor  of  the  older  classification,  there  is,  in  addition 

Tne  benign  • 

bubonic  or  to  the  phenomena  already  mentioned  as  occasionally  met 

Pestis  minor.  ^^^^^^  _^^  prodromata,  ill-defined  or  well-defined  fever,  pain 
and  tenderness  in  the  groin,  arm-pit,  or  neck,  with  the  appearance  at 
the  seat  of  pain  of  a  glandular  swelling  or  bubo,  tender  to  pressure 
or  on  movement  of  the  parts,  general  debility,  slight  congestion  of  the 
eyes,  and  slightly  thickened  speech.  This  is  the  acute  form,  which  may 
only  last  a  week,  the  symptoms  disappearing  after  the  patient  perspires. 
The  bubo  terminates  in  resolution,  suppuration,  or  induration.  The 
patient  may  not  take  to  bed  or  at  most  is  confined  to  it  for  only  a  few 
days.  In  the  more  chronic  form,  which  may  last  two  or  more  months, 
the  bubo  or  buboes  are  indolent  and  they  may  undergo  a  slow  process  of 
suppuration  and  sloughing,  constituting  a  serious  drain  on  the  general 
health  of  the  patient,  producing  anaemia  and  extreme  debility. 

In   the   so\ere  variety  of  the  bubonic   form,   which   often  includes 

septicaemic  and   pneumonic   cases,  and  which   is  usually 
The  grave  i  t"  J 

bubonic  or  described  under  Pestis  major,  the  invasion  of  the  disease 
major.  ^^  ^^  ^  ^^^j^  sudden  and  pronounced,  the  onset  being  abrupt, 
apparently  without  warning  and  frequently  coming  on  when  the  person 
attacked  is  at  work.  The  disease  is  often  fully  established  in  a  few 
hours  or  at  most  in  one  day.  The  symptoms  consist  of  shiverings  or 
tremblings,  with  fever  of  a  remittent  type,  hot  and  dry  skin,  flushed 
face,  injected  eyes,  nausea  and  vomiting  of  mucous  and  bilious  matter, 
diarrhoea,  severe  and  splitting  frontal  headache,  depression,  great  giddi- 
ness,'staggering  gait  when  walking,  as  if  intoxicated,  quickened  pulse 
and  respiration,  stabbing  pains  in   epigastrium,  back  and  loins,  white- 


CH.  xiv]  Clinical  Features  263 

coated  tongue,  which  is  red  at  the  tip  and  edges,  mouth  and  fences 
dry,  and  intense  thirst.  These  symptoms  differ  little  from  those  which 
characterise  the  onset  of  any  specific  disease,  and  have  nothing  to 
distinguish  them  at  this  early  stage  unless  they  are  associated  with 
glandular  enlargements  in  some  region  of  the  body.  If  a  bubo  appears 
it  is  usually  ushered  in  by  intense  pain  in  the  groin,  arm-pit,  or  neck, 
which  is  increased  by  movement  or  pressure.  The  pain  at  first  is  so 
severe  that  the  attention  of  the  patient  is  mainly  directed  to  it, 
all  other  symptoms  being  considered  insignificant  compared  to  the 
suffering  experienced  in  the  gland  affected.  The  pain  is  followed  by 
a  swelling  which  constitutes  the  bubo,  and  which,  small  and  tender  at 
first,  consists  of  a  single  gland  or  a  group  of  inflamed  glands,  the  outlines 
of  which  are  easy  to  define,  but  later  cannot  be  differentiated.  The 
bubo  may  remain  small,  hard  and  tense,  or  it  may  increase  in  dimensions 
and  form  a  brawny,  boggy  oedematous  swelling  the  size  of  a  man's  fist 
or  that  of  an  orange.  It  may  reach  a  large  size  in  a  few  hours  or  it 
may  take  several  days  for  its  full  development.  Gangrenous  pustules 
may  also  accompany  the  bubo  or  appear  later  on  different  parts  of  the 
skin,  and  petechiae  may  be  seen  in  some  cases  before  death.  If  there 
is  no  bubo,  the  .symptoms  may  be  those  of  pneumonia  or  of  extreme 
nervous  prostration  and  muscular  weakness,  and  instead  of  the  face 
being  flushed  it  may  be  pale  and  the  temperature  not  much  over 
100°  F.  As  the  disease  progresses  the  headache  and  vertigo  increase 
in  severity,  the  fever  rises  or  continues  at  its  maximum,  the  eyes 
assume  a  more  suffused,  congested,  and  sunken  appearance,  the  face  is 
drawn,  and  the  expression  is  either  anxious  and  denotes  suffering  or 
it  is  fixed  and  vacant.  There  is  much  restlessness,  with  an  uncontrollable 
desire  lo  wander  about  aimlessly  to  some  other  locality.  Profound  de- 
pression, great  prostration,  and  an  overpowering  sense  of  fatigue  set 
in.  Ordinary  consciousness  is  retained,  but  even  with  apparently  perfect 
consciousness  the  mental  condition  is  one  of  hebetude  or  drowsiness. 
The  intellect  loses  its  keenness  and  responds  slowly  to  outward  stimuli. 
Questions  are  answered  slowly,  the  words  or  sentences  being  articulated 
in  an  embarrassed  and  hesitating  manner,  each  syllable  being  pro- 
nounced slowly,  indistinctly,  and  with  difficulty,  or  the  speech  is  staccato 
in  character  and  uttered  in  a  hurried  and  irritable  tone.  Cerebral 
derangement  may  occasionally  be  absent  even  at  a  later  stage,  but 
usually  increasing  disturbance  of  the  nervous  system  quickly  follows, 
evidenced  by  protracted  sleeplessness  or  greater  drowsiness,  which  may 
alternate  with  delirium,  or  by  a  drowsy  and  lethargic  condition  which 


264  Plague  in  flu    //uJirUhiaJ  [part  m 

merges  inti)  jiiot'ound  t-oiiia.  The  deliiiiun  may  be  of  a  quiet,  noisy, 
furious,  or  terrifying  kind  ;  it  is  often  of  a  muttering  kind  with  rest- 
lessness and  picking  of  the  hed-clothes ;  but  it  may  be  violent  and 
there  may  be  much  difficulty  in  keeping  the  patient  in  bed.  The 
whitish  coating  of  the  tongue  turns  after  the  second  or  third  day 
to  a  brown  or  reddish-brown  colour,  while  the  tips  and  edges  remain 
red.  The  tongue,  which  was  moist,  now  becomes  dry,  and  sordes  appear 
on  the  lips  and  teeth,  the  urine  contains  albumen,  and  the  abdomen 
swells.  The  respiration  becomes  more  frequent,  accompanied  by  dyspnoea 
and  cough.  The  pulse,  which  is  soft  and  easily  compressible  at  the 
onset,  becomes  intermittent,  dicrotic  and  thready  and  difficult  to  count, 
and  there  is  a  tendency  to  collapse,  the  patient's  extremities  becoming 
cold  and  clammy.  Concun'ently  pneumonic  complications  are  apt  to 
arise. 

The  patient  may  die  from  the  disease  in  48  or  24  hours  or  even  less, 
Causes  of  ^^'i^h  all  the  symptoms  fully  developed,  or  death  may  be 

'^®^*^-  delaj-ed  to  any  time  between  the  third  and  seventh  day 

or  later,  but  it  usually  occurs  between  the  second  and  sixth  day,  and 
generally  takes  place  from  heart  feilure ;  it  may,  however,  be  brought 
about  by  exha\istion  or  collapse  caused  by  haemorrhage,  or  by  asphyxia 
by  pressure  of  the  buboes  and  surrounding  oedema  on  the  respiratory 
organs,  or  by  involvement  of  the  lungs,  or  by  coma  from  the  poisonous 
effect  of  the  toxines  on  the  nervous  centres. 

After  the  sixth  or  seventh  day  the  patient's  chances  of  recovery  are 
Progress  after     ^^^^ch  increased,  and  in  favourable  cases  the  fever  decreases, 

the  sixth  or  the  skin  perspires,  the  tongue  becomes  moist,  the  pulse 
seventh  day.  ,      ,  .  i       mi 

stronger,  and   the  expression  natural,     ihe  temperature 

is  usually  normal  about  the  tenth  day.    Once  convalescence  begins,  which 

may  be  on  the  sixth  or  eighth  day,  the  progress  may  be  rapid  or  it  may 

become  tedious  and  protracted,  and  the  patient  may  not  be  well  for 

six  to  ten  weeks  or  longer.     Sometimes  the  symptoms  do  not  improve 

on  the  sixth  or  eighth  day.     The  tongue  remains  dry,  reddish,  cracked, 

and  with  a  dark  coating,  the  teeth  and  lips  retain  their  sordes  and  a 

typhoid    condition    develops.      The   abdomen   becomes    more   swollen, 

the  diarrhoea,  if  any,  is  more   obstinate,  and  the   motions  ai'e  foetid  ; 

the  pulse   continues  frequent  and   irregular,  the   respiration   laborious, 

the  skin  alternates  between  dryness  and  a  state  of  perspiration,  the 

sleep  is  disturbed  and  unrefreshing,  and  the  patient  lies  in  a  condition 

of  apathy  and  stupor.     The  buboes  suppurate  and  discharge  an  offensive 

serous  fluid,  and  it  is  not  until  the  fifteenth  or  twentieth  day  that  there 


CH.  xiv]  Clinical  Features  265 

are  any  signs  of  convalescence,  or  it  may  happen  about,  this  time  that 
the  patient's  strength  gives  way  and  death  ensues. 

The  severest  forms  of  plague  are  those  that  are  classified  as  the 
septicaemic  and  pneumonic  varieties ;  they  correspond  to  the  Pestis 
siderans  or  malignant  form  of  the  older  writers,  and  generall}'  prove 
fatal  before  the  eruption  of  buboes. 

The  septic  variety  of  plague  is  a  virulent  type,  in  which  the 
Septicaemic  lymphatic  glands  usually  show  no  special  enlargement 
plague.  during    life    and    consequently    the    bubo    is   absent,   but 

after  death  the  glands  are  found  to  be  generally  affected,  being  some- 
what enlarged  and  much  congested.  In  this  form  of  plague  the  bacilli 
invade  the  blood  in  large  numbers  and  are  easily  detected.  The 
chief  characteristics  are  the  rapidity  with  which  nervous  and  cerebral 
symptoms  supervene  and  their  intensity.  The  patient  is  profoundly 
affected  by  the  amount  and  strength  of  the  poison  received,  which 
appears  to  concentrate  itself  on  the  central  nervous  system.  The  attack 
begins  with  trembling  and  rigors,  intense  headache,  vomiting,  and  high 
fever.  At  times  the  depression  of  the  vital  powers  is  so  great  that 
there  is  no  power  in  the  patient  for  reaction,  and  the  temperature  does 
not  reach  100°  F. ;  the  countenance  is  pale  and  the  expression  apathetic 
or  depicts  intense  anxiety.  Extreme  nervous  prostration,  weakness, 
drowsiness,  restlessness,  hurried  and  panting  respiration,  small  and  full 
pulse,  tympanitis,  delirium,  picking  of  the  bed-clothes,  stupor  and  coma 
quickly  follow  on.  The  evacuations  are  involuntary,  the  patient  becomes 
cold,  and  dies  on  the  first,  second,  or  third  day.  In  these  cases  there 
may  be  bleeding  from  the  nose,  kidneys,  and  bowels.  If  there  is  any 
reaction,  as  is  sometimes  the  case,  the  pulse  becomes  stronger,  the  face 
flushed,  the  eyes  congested,  and  on  the  third,  fourth,  or  fifth  day 
buboes  may  appear  simultaneously  in  the  groin,  arm-pit,  or  neck. 

In  pneumonic  plague  unaccompanied  by  buboes,  and  in  which  the 
Pneumonic  primary  localisation  of  the  disease  is  in  the  lungs,  the 
plague.  illness   commences  with  a  rigor,  general  malaise,  severe 

headache,  nausea,  vomiting,  and  pain  in  the  limbs,  followed  by  fever 
varying  in  range  from  102''  F.  to  105°  F.,  a  sense  of  constriction  across 
the  chest,  difficult  and  hurried  breathing,  cough  and  expectoration. 
In  other  cases  a  few  days  may  elapse  before  the  lung  symptoms  develop. 
Consciousness  is  generally  not  disturbed.  The  sputum,  at  first  watery 
and  frothy  and  tinged  with  blood,  generally  becomes  more  profuse  as  the 
disease  advances,  but  less  aerated.  Sometimes  it  is  scanty  and  consists 
of  small  })ellets  of  congealed  blood.     The  sputum  has  not  the  glairy 


266  Plagye  in  the  Tncliri final  [part  tit 

viscid,  rusty  character  of  that  of  acute  pneumonia,  though  on  the  clothes 
it  may  be  mistaken  for  this.  Physical  examination  does  not  reveal  signs 
of  sufficient  gravity  to  account  for  the  severity  of  the  symptoms.  On 
auscultation  the  stethoscopic  signs  may  be  those  of  lobular  pneumonia ; 
moist  sounds  and  crepitation  may  be  heard  over  the  pneumonic  patches, 
but  there  is  seldom  marked  dullness  at  the  base  or  at  the  spots  where 
crepitation  is  detected,  and  however  hurried  the  breathing  and  quick  the 
pulse  may  be  there  is  not  that  disproportion  between  the  pulse  and 
respiration  ratio  which  obtains  in  acute  pneumonia.  The  lung  symptoms 
and  cardiac  distress  rapidly  grow  worse,  delirium  supervenes,  there  is 
gradual  failure  of  the  heart's  action  with  or  without  coma,  and  death 
with  a  cyanosed  aspect  occurs  on  the  fourth  or  fifth  day  or  earlier.  This 
form  of  plague,  besides  being  the  most  infectious,  is  the  most  fatal. 
In  cases  which  recover  or  linger  for  some  time  buboes  are  likely  to 
appear,  and  in  some  cases  the  pneumonia  and  buboes  may  occur 
simultaneously  at  the  commencement  of  the  illness. 
[  In  each  of  these  forms  the  symptoms  more  or  less  common  are 
Characteristic  subject  to  many  modifications.  The  Pestica  facies  changes 
symptoms.  during  the  illness,  being  dependent  on  the  state  of 
consciousness  of  the  patient,  on  the  kind  of  delirium,  on  the  severity 
of  the  headache,  and  on  the  degree  of  giddiness  which  forms  part  of  the 
symptoms.  Many  have  injected  eyes,  a  distressed  aspect  of  countenance, 
the  eyelids  slightly  closed  and  the  mouth  slightly  open ;  some 
wear  an  expression  of  pain.  As  a  rule  the  countenance  in  the  early 
stages  depicts  anxiety  and  distress,  and  in  the  later  stages  resignation 
and  apathy.  The  resigned,  listless,  and  apathetic  countenance  is  apt 
to  deceive  the  physician,  causing  him,  unless  experienced  in  the  disease, 
to  entertain  the  opinion  that  the  patient  is  better,  Avhereas  it  is  due 
to  relaxation  of  the  facial  muscles  from  partial  loss  of  nervous  power 
and  is  not  an  improvement,  but  a  sign  of  gravity  and  danger.  With 
delirium  the  face  is  flushed  and  the  expression  may  be  one  of  dis- 
traction, anxiety,  terror,  or  menace,  the  patient  being  wild  with  ex- 
citement ;  the  eyes  are  red,  congested  and  sunken,  and  the  conjunctivae 
ai-e  injected.  In  a  state  of  stupor  the  expression  is  gloomy,  depressed, 
apathetic  or  vacant,  the  mouth  is  half  open  and  the  patient  has  the 
appearance  of  being  under  an  hypnotic  and  yet  unable  to  sleep,  the 
eyes  remaining  wide  open  or  half  closed,  glassy,  vacant,  and  lustreless. 

The  tongue  is  generally  swollen,  indented,  and  is  protruded  with 
difficulty  in  a  tremulous  or  jerky  manner;  it  is  coated  on  the  surface 
with  a  creamy- white  fur  with  angry  looking  papillae  showing  through, 


CH.  xiv]  Clinical  Features  267 

and  the  tips  and  edges  are  clean  and  I'od.  Later  the  coating  on  the 
surface  of  the  tongue  is  dry  and  has  a  mother-o'-pearl  or  glistening 
appearance ;  and  later  still  it  forms  into  a  yellowish  or  reddish-brown  or 
black  crust  and  resembles  that  seen  in  typhus  and  typhoid  fever.  The 
lips,  teeth,  and  gums  become  covered  with  sordes.  The  plague  virus 
evidently  produces  a  progressively  intoxicating  effect  on  the  nervous 
system,  which  dis})lays  itself  with  varying  degrees  of  intensity  in 
different  ways  on  different  constitutions.  In  some  there  is  insomnia, 
in  others  wild  delirium,  in  others  stupor,  in  all  more  or  less  loss  of 
coordinating  power  over  the  voluntary  muscles  and  dulling  of  the 
senses.  The  staggering  gait  and  the  inability  to  coordinate  the  move- 
ment of  the  hands  are  very  characteristic  symptoms.  There  is  no 
paralysis  of  the  limbs,  but  from  the  physical  weakness,  vertigo,  and  toxic 
impression  on  the  nervous  system  the  voluntary  muscles  are  not 
completely  under  the  command  of  the  patient.  The  speech  is  also 
peculiarly  hesitating,  stuttering,  thick,  lisping,  indistinct,  and  mono- 
syllabic, often  like  that  of  a  drunken  man.  The  memory  is  confused. 
and  in  answering  questions  the  patient  forgets  half  the  sentence  or 
syllable  of  the  word  which  he  began  to  utter.  It  has  happened  that 
a  plague  patient  with  these  symptoms  has  been  taken  to  the  police 
station  under  the  supposition  that  the  speech,  staggering  gait,  and 
confusion  of  mind  were  due  to  drunkenness. 

The    general    clinical    features    of   plague    in   its   different    forms 
Symptoms  having  been  described,  some  of  the  important  symptoms 

inTeiation  ^^'^^^^  ^^®  system  affected  may  now  be  more   fully  dealt 

to  systems  with. 

Tlie  temperature  is  not  characteristic;  it  rises  in  the 
Temperature.  ^^^^^^^[^  fo^m  to  103°,  104"  F.  or  may  be  to  105°  F.  or  to 
106°  F.,  and  may  reach  its  highest  on  the  evening  of  the  first  day  and 
continue  at  its  maximum,  but  more  usually  it  gradually  rises,  reaching 
its  maximum  on  the  evening  of  the  second  or  third  and  sometimes,  but 
seldom,  on  the  fourth  day,  an  intermission  of  a  degree  or  more  frequently 
taking  place  during  a  part  of  the  day.  On  the  third,  fourth,  or  fifth  day 
the  temperature  usually  falls  2  or  3  degrees  or  more,  continues  at  this 
low  temperature  for  a  few  hours  or  a  day  and  then  rises  again,  reaching 
nearly  the  same  or  a  greater  height  than  that  of  the  previous  evening. 
This  primary  fall  in  temperature  is  sometimes  ascribed  to  the  effect  of 
medicines,  but  it  is  a  feature  which  is  common  to  many  cases  of  plague 
when  left  to  their  natural  course.  With  this  secondary  rise,  especially 
if  higher  than  the  first,  the  symptoms  increase  in  gravity  and  the  patient 


268  Plague  in  the  Ju(lh'khi(d  [part  in 

is  in  a  perilous  condition.  It'  this  stage  is  successfully  passed  through, 
the  temperature  again  falls  the  next  day,  and  then  by  successive  evening 
exacerbations  and  morning  remissions  steadily  comes  down  by  degrees  to 
normal  or  sub-normal,  which  may  be  reached  on  any  morning  between 
the  sixth  and  eleventh  day.  In  simple  bubonic  cases  of  a  mild  character 
the  temperature  may  fell  to  normal  as  early  as  the  second  or  third  day ; 
on  the  other  hand  the  occurrence  of  complications  or  the  eruption  of 
buboes  may  cause  great  irregularity  in  the  temperature  and  completely 
obliterate  the  more  or  less  typical  primary  and  secondary  rise  with  the 
apyrexial  interval. 

Little  is  to  be  gathered  as  regards  prognosis  from  the  temperature ; 
generally  the  higher  the  temperature  the  graver  are  the  symptoms ;  and 
the  later  the  first  curve  terminates  the  more  likely  is  the  secondary 
reaction  to  be  moderate.  Fluctuating  temperatures  may  mean  nothing* 
but  if  simultaneously  with  the  fall  of  temperature  there  is  a  considerable 
rise  in  the  frequency  of  the  pulse,  the  conjunction  is,  as  a  rule,  un- 
favourable. A  sudden  fall  of  temperature  with  a  collapsed  condition  of 
the  patient  usually  indicates  a  fatal  issue ;  on  the  other  hand,  a  fall 
of  temperature  by  degrees  between  the  fifth  and  seventh  day  may  be 
looked  upon  as  favourable.  Sometimes  the  temperature  is  low  and 
becomes  subnormal. 

Occasionall}^  there  may  be  no  fever  during  the  illness,  which  may 
merely  consist  of  indisposition,  coated  tongue,  headache,  slight  giddiness, 
and  a  bubo  in  groin,  arm-pit,  or  neck.  The  illness  is  such  as  not  to  con- 
fine the  patient  to  bed,  but  is  often  protracted  and  sometimes  terminates 
suddenly  in  death. 

In  septicaemic  plague  the  temperature  is  usually  high  at  the  com- 
raencemcnt,  remains  high,  and  runs  an  irregular  course.  In  the  most 
severe  cases  of  the  septicaemic  type  the  temperature  may  not  rise 
above  100°  F.  or  less  in  the  early  stage,  and  it  is  only  if  the  patient 
lives  long  enough  for  reaction  to  set  in  that  there  is  any  considerable 
rise  in  temperature. 

In  pneumonic  plague  the  temperature  is  high  and  usnall}'  runs  an 
irregular  course.  It  may  continue  high  to  the  end  or  f;ill  suddenly 
before  the  patient's  death. 


CH.  XIV] 


Teinperattire  Charts 


269 


The  Charts  taken  from  Surg  eon- Major  Lyon's  Report  on  the  Plague  in 
Bombay,  and  from  DrJ.  A.  Lowsorts  Report  on  Plaque  in  Hongkong,  and  from 
some  Cape  Town  cases  will  shoiv  the  general  character  of  the  temperature  in 
plague. 

J.G.G.(E)    L.  Fkm.  Bubo  Suppurated  Rec. 


Day 

F 

106 

105 

104 

105 

102 

101 

WO 

99 

38 

97 
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P^v 

P.S.(H)     L.  Fem.  Bubo  Suppurated  Eec. 


270 


Plague  in  the  Iiullvklual 


[part  III 


A.K.H.(M)    Left  Axillary  Bubo. 


W.(E)     L.  Fem.  BuiJo  Resolution  Rec. 


Day 

F 

lib 

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lOi 

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100 

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Pulse 

Resp. 


Right  Femoral  Bubo. 
1  2  3 


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CII.  xiv] 


Temper atu) 'e  Ch at -ts 

Left  Axillary  Bubo. 


271 


29     30        1         2         3        4        6        6        7       8       9      10      1 1      12     13     H      16 


Lei't  Cehvical  Bubo. 


Ttmf 

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272 


Plague  in  the  Individual  [part  ttt 


M.K.     Pneumonic  Plague. 


APRIL       19 

APRIL     20 

APRIL     21 

APRIL      22 

APRIL     23 

A.M. 

P.M. 

A.M. 

P.M. 

A.M.     P.M. 

A.M. 

P.M. 

A.M. 

P.M.  1 

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G.D.     Septic.\emic  Pl.^gue. 


MARCH     27 

MARCH     28 

MARCH     29 

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A.M.      P.M. 

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A.M.       P.M. 

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CH.  xiv]  Clinical  Fecit tires  273 

Contemporaneously  with  the  fever,  or  before,  or  soon  after  its 
Lvmoiiatic  appearance,  in  some  cases  several  days,  and  in  rare  cases  a 
system  week  or  more  later,  intense  pain  is  felt  in  one  or  more  of 

the  glandular  regions  of  the  body,  generally  in  the  femoro- 
inguinal,  axillary  or  cervical  region,  or  occasionally  in  thv  epitrochlear 
or  popliteal  space.  At  the  seat  of  pain  one  or  more  of  the  glands  is 
noticed  to  be  swollen  and  to  be  specially  tender  on  pressure.  In  the 
next  12  hours  or  in  a  shorter  time  the  swelling  rapidly  increases  in  size 
and  a  bubo  is  formed.  Sometimes  more  than  one  region  is  affected, 
and  often  groups  of  glands  on  the  same  course  of  lymphatics  become 
successively  infected.  As  a  rule  only  one  region  of  the  body  is  affected, 
though  in  a  small  percentage  of  cases  buboes  may  appear  of  a  bilateral 
or  multiple  character  in  any  part  of  the  lymphatic  glandular  system. 
The  bubo  may  be  completely  formed  in  a  few  hours,  but  more  fre- 
quently its  full  development  takes  from  one  to  five  days. 

The  bubo  or  swelling  consists  of  one  or  more  inflamed  and  swollen 
lymphatic  glands  with  a  sero-sanguinolent  or  hacmorrhagic 
condition  of  effusion  into  the  periglandular  tissue,  which,  while  matting 
°^^'  together  the  neighbouring  glands  into  a  hard  mass,  also 

infiltrates  the  tissues  around  and  renders  them  firm  and  oedematous. 
The  periglandular  tissue  like  the  glands  becomes  inflamed.  The  effusion 
may  be  profuse  or  scanty.  In  cases  which  prove  rapidly  fatal  the 
glands  may  remain  hard  and  painful  without  any  palpable  periglandular 
infiltration,  but  the  usvial  course,  if  the  patient  lives  long  enough,  is 
extreme  pain,  swelling  of  the  gland  or  glands,  effusion,  and  the  forma- 
tion of  a  distinct  bubo. 

The  discovery  of  the  plague  bacillus  in  the  blood  in  nearly  45  "/o  of 
the  cases  of  plague  admitted  into  hospital  in  Bombay  in  recent  years, 
and  the  still  greater  percentage  in  Hongkong,  would  seem,  as  already 
stated,  to  indicate  that  the  older  views  were  more  correct  than  the 
modern,  and  that  the  bubo  in  most  cases  is  only  a  local  manifestation 
of  the  disease  already  in  the  blood.  Every  extravasation  whether  on 
the  skin  or  elsewhere  contains  plague  bacilli. 

The  fact  of  the  bubo  frequently  making  its  appearance  several 
days  after  the  onset  of  the  illness  is  also  in  favour  of  plague  being 
primarily  a  general  disease,  the  affection  of  the  glands  with  the 
eruption  of  the  bubo  or  buboes  being  a  local  manifestation  of  the 
disease  as  much  as  the  skin  eruption  in  small-pox,  scarlet  fever,  or 
measles.  This  view  is  contrary  to  that  commonly  accepted  to-day, 
which  considers  the  bubo  to  be  the  primary  local  lesion,  the  toxines 
s.  18 


274  Placjue  in  the  TndivUlual  [part  hi 

from    which  become    absorbed    and    give    rise    to    the    general    symp- 
toms. 

The  smaller  the  bubo  usually  the  more  fatal  is  the  attack.  The 
size  of  the  bubo  depends  on  the  number  of  glands 
affected  and  the  amount  of  effusion  matting  the  inflamed 
glands  together  and  infiltrating  into  the  surrounding  tissues.  When 
the  effusion  is  small  the  bubo  may  be  no  larger  than  an  almond 
and  the  affected  glands  may  be  distinctly  felt,  but  when  the  quantity 
of  periglandular  fluid  is  large  it  may  be  the  size  of  a  man's  fist 
or  larger;  then  the  outline  of  the  glands  is  not  to  be  discovered  by 
palpation.  The  bubo  is  usually  of  an  oval  or  round  shape  and  of  uneven 
surface  owing  to  the  conglomeration  of  affected  glands.  At  first 
moveable  from  surrounding  structures  it  becomes  adherent  and  im- 
moveable, it  is  somewhat  doughy  or  boggy  to  the  touch  on  the  surface 
and  of  a  hard  consistence  in  the  deeper  tissue.  The  skin  over  the  bubo 
loses  its  soft  and  loose  texture,  becomes  thickened,  appears  smooth  and 
tense,  and  is  sometimes  reddened  or  of  a  dusky  hue  from  inflammatory 
action.  On  the  surface  of  the  bubo  may  be  haemorrhages,  carbuncles  or 
blisters,  and  the  skin  covering  the  bubo  may  become  gangrenous. 
Pain,  tenderness,  and  swelling  are  the  general  character- 
istics of  the  bubo.  The  pain  may  be  dull  and  aching 
or  sharp  and  stabbing,  and  is  independent  of  the  size  of  the  bubo.  The 
smaller  the  size  of  the  bubo  the  more  painful  is  it  likely  to  be.  Much 
of  the  pain  disappears  as  the  swelling  increases  in  size.  Sometimes 
there  is  no  pain,  and  the  bubo  when  lying  deep  is  only  detected  by  the 
tenderness  caused  by  pressing  over  the  part.  Sometimes  there  is  neither 
pain  nor  tenderness  and  the  bubo  can  be  handled  without  causing  any 
Tenderness  inconvenience  to  the  patient.  Tenderness  on  pressure 
over  the  region  of  the  glands  is  useful  in  a  confirmatory 
sense  when  the  glands  are  small  or  lie  so  deep  as  not  to  be  felt,  but 
absence  of  tenderness  does  not  always  mean  no  affected  glands.  Some- 
times the  tenderness  is  so  acute  that  pressure  over  the  bubo  will  cause 
wincing  and  moaning  from  pain  even  when  the  patient  is  in  a  comatose 
condition.  In  the  acute  stage  of  development  if  the  bubo  is  cut  into 
it  will  bleed  freely  and  the  swollen  glands  will  present  a  brick-red  or 
purple  colour.  At  a  later  stage  a  similar  incision  will  usually  show 
yellow  or  blood-stained  pus. 

The  bubo   in  its  natural  course  terminates  by  suppuration   or   by 

Termination       •'^l"»ghing,  or  it  subsides  by  resolution,  becoming  dispersed 

and  absorbed,  or  it  indurates  and  remains  as  a  hard  lump 


CH.  xiv]  Clinical  Features  '21q 

for  an  indefinite  period.  In  the  event  of  suppuration,  if  the  case  is  an 
uncomplicated  one,  the  process  begins  after  the  seventh  or  eighth  day 
without  any  rise  of  temperature,  the  skin  over  the  infiltrated  area 
becoming  inflamed,  and  is  completed  in  the  course  of  ten  or  twelve  days. 
The  suppurating  bubo  heals  in  the  course  of  a  week  to  a  month,  leaving 
a  large  scar,  more  or  less  varying  in  size  according  to  the  amount  of 
sloughing  which  has  taken  place.  The  healing  process  may,  however, 
not  be  completed  for  six  weeks  or  two  months  or  longer.  Indolent 
buboes,  especially  those  in  the  iliac  regions,  may  not  suppurate  for  long 
periods.  Choksy  records  a  case  of  a  bubo  of  this  kind  being  opened 
on  the  48th  day  of  the  patient's  illness  ^ 

When  the  suppuration  is  accompanied  as  it  may  be  by  much 
sloughing,  either  of  the  bubo  or  of  the  bubo  and  the  infiltrated  tissue 
around  it,  large  cavernous  ulcers  with  rugged  and  indurated  margins 
may  result,  laying  bare  the  muscles,  nerves,  and  blood  vessels  of  the  part 
and  forming  deep  and  unhealthy  looking  wounds  which  take  a  long  time 
to  heal  and  which  are  a  heavy  drain  on  the  patient's  strength.  These 
large  sloughing  excavations,  which  are  at  all  times  dangerous,  are 
specially  so  when  they  occur  in  the  pelvis  in  connection  with  iliac 
buboes. 

The  pus  in  mild  cases  is  healthy  and  presents  no  unusual  characters, 
but  in  the  more  severe  cases  it  varies  much,  sometimes  being  offensive 
and  serous,  at  other  times  being  chocolate  colour  and  like  wine  lees  and 
mixed  with  coagulated  blood. 

If  the  bubo  ends  in  resolution  the  periglandular  infiltration  de- 
creases, the  outlines  of  the  glands  get  more  distinct,  the  glands  lose 
their  tenderness  on  pressure,  the  skin  becomes  softer,  and  beyond 
a  slight  induration  and  possibly  a  pigmenting  of  the  skin  there  is  little 
trace  of  the  inflammation  to  which  the  glands  and  their  surroundings 
have  been  subjected. 

The  situation  of  the  buboes  in  order  of  frequency  in  the  external 

glandular  region  is  the  same  in  every  country  where  plague 
Situation  j  ./  i      o 

occurs,  whether  the  inhabitants  wear  boots  or  not.     The 

most  frequent  seat  for  them  is  the  inguino-femoral  region,  the  next  is 

the  axillary,  and  the  next  the  cervical. 

A  patient  suffering  from  an  inguinal  bubo  usually  lies  in  bed  with 

Inguinal  the  thigh  flexed  to  relieve  any  pressure  on  the  painful 

buboes.  swelling.     In  the  inguinal  region  the  bubo  may  occupy 

a   horizontal    or   vertical    position,  according   to  the  group   of  glands 

'   The  Treatment  of  Phu/iw  with  Prof.  Lustirj's  Serum.     By  N.  H.  Choksy,  M.D. 

18—2 


•276 


Plaffue  in  flic   TntJividual  [part  ill 


Inguinal     Bubo. 


Inguinal    Bubo. 


CH.   XIV] 


Clinical  Feahu^es 


277 


that  may  be  specially  affected  in  Scai'pa'.s  triangle.  The  vertical 
set  of  glands  below  Poupart's  ligament  are  the  most  frequently  affected. 
The  swelling  may  be  small  or  it  may  be  as  large  as  an  orange,  and  the 
oedema  of  the  surrounding  tissues  may  extend  as  far  as  the  knee  or  well 
on  to  the  abdominal  wall.  The  figures  on  p.  276  show  the  kind  of  buboes 
most  commonly  met  with  in  the  inguinal  region.  Only  one  groin  may 
be  the  seat  of  a  bubo  or  bc^th  groins  may  be  affected.  The  bubo  in  the 
inguinal  region  not  infrequently  extends  into  the  iliac  region,  affecting 
the  chain  of  glands  and  lymphatics  in  the  abdominal  cavity  and  forming 
a  hard  tumour  to  be  felt  through  the  abdominal  wall.  This  iliac  bubo 
is  painful  on  pressure  and  may  attain  large  dimensions.  Sometimes 
these  iliac  buboes  occur  without  any  very  noticeable  enlargement  of 
the  inguinal  glands,  and  may  if  situated  on  the  right  side  be  mistaken 
for  the  results  of  typhlitis  or  appendicitis. 


Axillary    Bubo. 


278 


Plagtie  in  the  Individual 


[part  III 


Patients    with    axillary    buboes    usually   lie   on  the  back   with  the 
AxiUary  affected  arm  held  away  from  the  side.     In  the  axilla  the 

buboes.  bubo  often  occludes  the  axillary  space  and  obliterates  the 

outline  of  the  margin  of  the  pectoralis  major.  The  exudation  may 
become  much  greater  than  that  accompanying  inguinal  buboes,  and  may 
extend  over  the  side  of  the  chest  down  to  the  loins  and  upwards  to  the 
shoulders,  and  even  to  the  side  of  the  neck.  The  result  of  this  extensive 
sero-sanguiuolent  effusion  is  the  formation  on  the  side  of  the  patient  of 


-  '■  '^Ht^ 


Left  Axillary  Bubo  with  Infiltration  into  Chest, 
Shoulder  and  Arm. 


a  hard  mass  which  is  apt  to  interfere  very  materially  with  the  respiratory 
movements  or  become  a  dangerous  slough.  Incision  does  not  lessen  the 
swelling,  there  being  little  exudation  from  the  wound,  which  soon 
becomes  dry  and  heals  readily.  The  fluid  that  does  exude  does  not 
coagulate  spontaneously  but  coagulates  on  heating  and  on  the  addition 
of  nitric  acid.     Axillaiy  buboes  with  extensive  exudation  usually  end 


CH.   XIV] 


Clinical  Features 


279 


fatally.  Sometimes  an  axillary  bubo  will  cause  swelling  of  some  of  the 
cervical  glands.  It  has  been  observed  that  axillary  buboes  are  fre- 
quently associated  with  septicaemic  and  secondary  pneumonia. 

Buboes  of  the  cervical  region  may  be  under  the  jaw  or  at  its  angle, 
Cervical  ^^  the  neck  and  in    the   tonsils.     The  swelling  in    these 

buboes.  situations  may  be  small,  and  the  disease  run  an  ordinary 

course,  or  it  may  be  so  great  as  to  place  the  patient  in  imminent  danger 
of  suffocation.  The  oedema  may  extend  down  below  the  clavicles  or  to 
the  chest  and  into  the  axilla,  or  upwards  to  the  face  and  head,  or  inwards 
into  the  soft  tissues  with  consequent  pressure  on  neighbouring  organs. 


Cervical    Bubo. 


•280 


Plague  In  the  Individual 


[part  III 


The  trachea  is  subjected  t<>  more  or  less  pressure  and  the  glottis  is  apt 
to  become  oedematous.  In  these  cases  the  patient  lies  down  with  head 
thrown  back  or  sits  up  in  bed,  breathes  hurriedly  and  with  difficulty,  the 
respirations  being  wheezy  and  stridulent,  and  the  pharynx  more  or  less 
fixed  and  immobile  during  inspiration,  the  voice  is  nasal,  there  is  much 
difficulty  in  opening  the  jaw  and  the  sputum  contains  blood  and  plague 
bacilli.  The  lips  and  cheeks  may  become  cyanosed  or  the  face  may  be 
pallid.  Patients  suffering  from  this  form  of  the  disease,  which  is 
generally  tonsillar  in  its  character,  with  the  mucous  membrane  of  the 
tonsils,  pharynx,  and  larynx  highly  inflamed,  infiltrated,  with  serous 
effusion,  and  sometimes  covered  with  a  pseudo-diphtheric  membrane, 
present  very  similar  symptoms  to  those  attacked  with  diphtheria.  In 
many  epidemics  the  early  cases  of  this  type  have  been  mistaken  for 


Cervical    Bubo. 


CH.  XIV] 


Clinical  Features 


281 


diphtheria.  This  was  the  case  in  Bombay,  where  some  of  the  earlier 
cases  of  plague  with  swollen  cervical  glands  were  diagnosed  as  diphtheria. 
The  sloughing  of  the  skin  over  cervical  buboes  reminds  one  of  what  was 
seen  in  cases  of  scarlet  fever  when  the  cases  were  more  malignant  than 
they  are  at  the  present  day. 


Popliteal  Bubo. 


282 


Plaffue  in  the  Tndwidiial 


[part  III 


Cervical    Bubo   and   Necrosis   on    Left    Ai 


CH.   XIV] 


Clinical  Features 


283 


Buboes  occasionally  occur  on  other  sites  than  those  mentioned  ;  in 
fact  they  may  be  found  wherever  glands  exist.  The  most  common  of 
these  unusual  sites  are  the  epitrochlear  region  and  popliteal  space,  but 
the  glands  of  the  breast,  testicle,  or  other  parts  may  be  exceptionally 
affected  with  buboes. 


^ifiT'^'Cv 


,^ 


Supra-trochlear    Bubo    and    Necrosis    on    Arm. 

]\Iultiple  buboes  may  also  occur  either  in  regions  in  close  proximity 
Multiple  to  the  primary  bubo  or  in  distant  regions,  or  contiguous 

buboes.  buboes  may  appear  almost  simultaneously.     In   the   first 

case  it  is  generally  held  that  the  pathological  evidence  indicates  the 
passage  of  the  bacillus  to  the  dther  glandular  group  by  the  chain  of 
glands  and  lymphatic  vessels  connecting  them,  or  by  the  oedema  formed 
from  the  first  affected  gland.  Contiguous  buboes  most  frequently  occur 
in  the  femoral  inguinal  and  iliac  regions  and  often  within  a  few  hours 
of  the  onset  of  the  disease.  Although  clinically  these  are  all  that 
are  discernible  the  post-mortem  examination  usually  shows  buboes, 
haemorrhages  and  swollen  glands  in  the  deeper  tissues  of  the  thoracic, 
abdominal  and  pelvic  cavities.  In  the  case  of  buboes  occurring  simul- 
taneously in  such  distant  parts  as  the  groin  and  axilla  it  is  accepted 


-^4  Plag}(e  w  the  Individual  [part  m 

that  they  can  only  be  caused  by  bacilli  being  carried  by  the  blood  stream 
to  the  affected  glands.  In  severe  septicaemic  cases  however  the  glands 
of  the  whole  glandular  system  of  the  body  are  affected,  but  they  do  not 
pass  the  stage  of  engorgement  and  slight  swelling  and  clinically  are  not 
readily  recognisable  in  the  groin,  arm-pit,  or  other  region.  In  these 
cases  extensive  multiplication  of  the  bacilli  takes  place  in  the  blood 
rather  than  in  the  glands. 

Petechiae  of  variable  size  and  pustules  forming  necrotic  patches,  or 
The  skin.  what  were  formerly  called  carbuncles,  may  appear  on  the 

Petechiae.  buboes  or   independently   of    them.     The   petechiae   are 

generally  over  buboes  or  on  the  abdomen,  but  they  may  be  found  in 
other  parts  of  the  body,  such  as  the  face,  neck,  breast,  and  extremities. 
Larger  ecchymotic  patches  are  occasionally  seen.  The  petechiae  and 
ecchymotic  patches  probably  correspond  to  the  tokens  in  the  Great 
Plague  of  London  Avhich  appear  to  have  been  a  common  feature  in 
fatal  cases.  Neither  petechiae  nor  ecchymoses  have  formed  important 
sjinptoms  in  the  different  epidemics  of  the  present  pandemic,  but  they 
are  occasionally  seen  well-marked  in  severe  cases  before  death.  In 
addition  to  patches  of  dark-coloured  petechiae  or  ecchymoses  there  has 
been  occasionally  an  eruption  of  pustules.  The  pustules  on  the  skin 
may  be  of  a  variable  nature,  and  in  some  cases  of  plague  they  have 
been  so  numerous  as  to  raise  a  doubt  as  to  whether  it  was  not  a 
case  of  small-pox  that  was  being  dealt  with.  This,  however,  is  excep- 
tional, but  it  is  possible  that  this  pustular  form  of  plague  was  more 
common  in  some  of  the  older  epidemics. 

More  commonly,  but  still  rarely  as  compared  with  the  epidemics 
Gangrenous  **^  former  days,  there  is  a  slight  eruption  of  a  few  pustules 
pustules  or  or  carbuncles  in  the  course  of  the  disease  and  after  the 
appearance  of  the  bubo.  They  may  appear  in  any  part 
of  the  body  and  at  any  period  of  the  acute  stage  of  the  illness.  The 
pustules  usually  commence  as  ecchymotic  or  petechial  spots,  having  the 
appearance  of  a  flea-bite  and  with  the  same  burning  sensation  in  them ; 
these  ecchymotic  patches  rapidly  increase  in  size  and  then  rise  in  the 
form  of  blisters  with  or  without  umbilication,  while  the  circumference 
becomes  hard,  swollen  and  inflamed.  The  blisters  contain  at  first  a 
clear,  serous  fluid,  which  is  later  dark,  sero-sanguinolent  or  haemorrhagic  ; 
and  in  the  contents  are  plague  bacilli.  The  blisters  soon  break  and 
show  at  their  base  a  moist,  bluish-red,  inflamed  and  angr^^-looking 
circular  or  irregular  patch,  which  at  this  stage  may  dry  up  and  go 
no  further,  or  the  inflamniation  iii;iv  extend  to  the  subcutaneous  tissue, 


CII.  xiv] 


Clinical  Features 


285 


causing  a  circumscribed  ur  diffuse  swelling,  the  centre  of  which  begins 
in  a  few  hours  to  necrose,  forming  a  leathery-looking  scab.  From  this 
centre  the  necrosis  spreads  rapidly  to  the  periphery.  The  result  is  the 
formation  of  indolent  ulcers  more  or  less  deep  or  superficial  with  hard 
and  red  overhanging  margins.  The  necrosis  may  stop  when  the  patch 
has  reached  a  circumference  of  one  or  two  inches,  which  is  the  usual 
limit,  but  in  some  cases  it  may  continue  to  spread  to  the  diameter 
of  even  eight  or  twelve  inches,  laying  bare  the  muscles,  the  nerves 
and  blood  vessels,  and  even  the  bones,  and  sometimes  causing  severe 
haemorrhage.  The  slough  is  thrown  off  by  suppuration  and  the  drain 
on  the  strength  of  the  patient  is  proportional  to  the  size  and  number 
of  ulcers  formed  by  these  gangrenous  pustules.  They  may  occur  in  all 
parts  of  the  body,  the  largest  having  been  noticed  in  the  gluteal  and 


Right  Inguinal  Bubo  and   Necrosis  or  Carbuncle  on   Loin. 

scapular  region.     Choksy  has  obsei'ved'   that  the  mortality  of  plague 
cases  in  which  these  cellulo-cutaneous  necroses  occur  is  less  than   the 

>   The  Treatment  of  Plague  icith  Prof.  Liistiy's  Serum.     By  N.  H.  Choksy,  M.D. 


286 


Plague  in  the  Individual 


[part  III 


bubonic  type  without  them.  A  similar  observation  was  made  in  Egypt 
in  the  epidemic  of  1834-35,  in  which  their  occurrence  was  considered 
favourable.  In  the  latter  epidemic  the  so-called  carbuncular  variety 
appeared   only  at  the   middle  and   decline  of  the  epidemic  when  the 


Carbuncle    or    Necrosis. 


type  of  the  disease  was  less  fatal.  In  a  small  percentage  of  cases  a 
single  pustule  on  the  wrist  or  ankle  or  other  part  of  the  body  appears 
at  the  commencement  of  the  disease.  If  on  the  wrist  or  ankle,  a  bubo 
usually  occurs  in  the  axilla  or  inguinal  region  of  the  same  side.  In 
such  cases  the  mortality  is  less  than  in  those  in  which  an  eruption  of 
pustules  manifests  itself  during  the  course  of  the  disease.  Plague 
bacilli  with  pyogenic  organism  are  to  be  detected  in  the  early  stage  in 
the  pustules  single  or  multiple. 


CH.  xiv]  Clinical  Features  287 

Next  to  the  eruption  of  buboes  the  most  characteristic  symptoms 
Nervous  ^"^^   those  connected  with   the   nervous  system.     Most  of 

phenomena.  these  have  already  been  mentioned,  such  as  at  the 
conmaencement  of  the  illness  the  great  depression,  severe  headache, 
giddiness,  staggering  gait,  and  stammering  speech.  The  headache  is 
usually  frontal,  though  it  may  not  be  confined  to  any  special  part,  and 
is  not  infrequently  general.  It  is  sometimes  dull  but  more  commonly 
acute  in  character.  Restlessness  and  a  desire  to  wander  from  one 
place  to  another  are  often  exhibited  in  the  early  stage.  Sleep  is  only 
obtained  in  snatches  and  is  unrefreshing.  As  the  disease  progresses  the 
disturbing  effect  of  the  toxines  manifests  itself  on  the  intelligence  in  a 
marked  degree,  though  this  is  not  always  the  case.  There  are  cases  in 
which  the  patient  remains  conscious,  rational,  and  with  speech  unaffected 
to  the  last,  not  an  uncommon  occurrence  in  primary  pneumonic  plague. 
Mental  clearness  is,  however,  the  exception,  but  it  sometimes  occurs. 
It  is  of  no  special  prognostic  value.  Heaviness,  drowsiness,  confusion 
of  ideas  and  a  state  of  hebetude,  alternating  with  delirium  of  a  low 
muttering  or  excited  nature,  are  the  most  characteristic  mental  con- 
ditions. They  come  on  early  in  the  disease.  The  delirium  may  be 
continuous  or  only  present  at  night,  or  it  may  be  absent,  and  the 
patient  remain  in  a  semi-conscious  condition.  There  are  all  transition 
stages  of  mental  condition,  from  that  in  which  the  patient  is  easily 
aroused  and  answers  questions  slowly  but  with  difficulty  in  a  somewhat 
hesitating  and  stammering  manner,  to  that  in  which  he  is  in  a  state 
of  stupor,  with  all  the  senses  dulled,  difficult  to  arouse,  and  if  he 
answers  it  is  in  a  muttering,  indistinct  and  almost  unintelligible  manner, 
like  that  of  a  drunken  man.  There  may  be  complete  aphasia,  the 
patient  being  unable  to  speak  from  paralysis  of  the  laryngeal  muscles. 
The  dumbness  may  continue  during  convalescence  and  sometimes  after 
recovery.  The  sense  of  taste  may  be  perverted  or  lost  during  the 
illness.  The  delirium  has  already  been  described  as  being  noisy  or 
of  a  quiet  character.  It  may  be  so  violent  as  to  necessitate  the  patient 
being  put  under  restraint  in  bed  to  prevent  self-injury  or  escape  from 
the  sick-room ;  sometimes  it  is  accompanied  by  suicidal  or  homicidal 
tendencies  and  by  hallucinations  of  a  terrifying  nature.  The  acute 
forms  of  delirium  are  more  frequent  than  the  low  muttering  variety. 
At  the  later  stages  hyjjeraesthesia  of  the  skin,  ti-emors,  twitchings 
and  spasms  of  the  muscles  of  the  face,  neck,  limbs,  abdominal  wall 
or  chest,  with  convulsive  seizures  of  the  body,  occasionally  mark  the 
strong  irritating  and  toxic  effect  of  the  virus  on  the  nervous  system. 
On  the  other  hand  the  action  of  the  virus  may  be  that  of  an  hypnotic ; 


288  Pla<in(    In  tin    IndirUUial  [part  hi 

then,  instead  of  gesticulations  and  incessant  talking,  the  patient  lies 
with  lixed  gaze,  indifferent  to  surroundings,  with  facial  muscles  relaxed, 
powers  of  articulation  lost,  and  in  a  state  of  nuiita]  and  physical  inertia. 
If  the  patient  recovers  the  improvement  is  at  most  very  gradual,  and 
at  times  there  may  remain  as  sequelae  a  state  of  dementia,  aphasia, 
or  ataxia,  which  may  be  temporary  or,  rarely,  permanent.  One  of  the 
features  of  plague  in  those  that  recover  is  that  the  cerebral  and 
nervous  disturbances  from  which  they  have  suffered  are  mostly  functional 
in  their  nature,  and  do  not  commonly  cause  any  permanent  injury. 

A  feeling  of  oppression  is  frequently  experienced  over  the  praecardial 
Vascular  regions.     In  mild  cases  of  plague  there  may  be  no  devia- 

system.  ^Jq,^   ^f  |^|^^  pulse  from  normal,  but  in   the   more  or  less 

severe  cases  weakness  soon  displays  itself,  and  in  proportion  to  the 
severity  of  the  nervous  phenomena,  the  pulse  shows  signs  of  a  tendency 
to  heart  failure  produced  by  the  paralysing  effect  of  the  plague  toxines. 
In  connection  with  this  are  the  frequency  of  the  pulse  and  the  rapid 
fall  in  arterial  tension.  Even  on  the  second  day  the  pulse  rate  will  rise 
to  120,  130,  or  140.  At  first  full  and  somewhat  frequent  the  pulse  soon 
becomes  feeble,  rapid,  intermittent  and  dicrotic,  and,  at  last,  in  cases 
likely  to  be  fatal,  so  thready  that  it  is  impossible  to  count.  Sometimes 
heart  failure  may  suddenly  occur  -without  any  sign  of  collapse.  Sudden 
exertion,  such  as  sitting  up  in  bed  or  getting  out  of  bed,  may  be  the 
immediate  cause  of  heart  failure,  but  this  may  happen  also  without 
any  such  strain  on  the  heart's  action. 

Lowson  gives  three  sph3'gmographic  tracings  of  the  pulse  in  plague 
which  are  here  reproduced.  Two  are  of  the  radial  pulse  and  one  of  the 
femoral,  the  first  radial  tracing  showing  the  dicrotic  pulse,  the  second 
radial  and  femoral  illustrating  the  anacrotic  pulse  preceding  failure. 

His  description  of  the  tracings  is  as  follows : 

"  The  pulse  which  at  first  is  full  and  bounding  becomes  (usually 
in  from  six  to  thirty-six  hours)  dicrotic  and  fairly  easily  compressible 
at  the  wrist.  The  accompanying  tracing  shows  such  a  pulse  where  the 
dicrotism,  although  not  extreme,  is  w^ell  marked. 


"  Intermittency  is  often  noticeable  in  this  second  stage  of  the  pulse 
and  becomes  more  marked  as  the  third  stage  develops,  when  it  becomes 
anacrotic  and  almost  like  the  pulse  of  aortic  insufficiency,  there  being 


CH.  XIV] 


Clinical  Features 


289 


no  rebound  wave  at  all,  nor  the  slightest  trace  of  it  by  sphygmograph 
in  a  well-marked  case.  In  addition  it  is  at  this  period  very  easily 
compressible,  and  the  actual  range  of  movement  of  the  vessel  is  very 
limited  at  the  wrist,  whereas  in  the  larger  vessels  the  upheaval  is 
usually  well  marked,  slight  pressure  at  the  femoral  being  sufficient  to 
arrest  the  pulse.  The  following  tracing  of  the  radial  pulse  is  taken 
from  a  patient  at  this  stage,  there  being  no  pressure  on  the  sphygmo- 
graph button  exce])t  its  own  weight. 


"  This  patient  was  a  very  lean  man,  and  consequently  a  tracing  of 
his  femoral  pulse  could  be  easily  obtained  as  the  vessel  passed  over  the 
brim  of  the  pelvis.  With  slightly  over  an  ounce  of  pressure  (enough 
to  visibly  diminish  the  range  of  movement)  the  accompanying  tracing 
was  got. 


"  From  this  anacrotic  stage  gi-adual  or  sudden  failure  may  set  in, 
unless  there  is  a  general  improvement  in  the  case.  The  pulse  generally 
becomes  fast  and  running  and  scarcely  perceptible  or  if  perceptible  it 
is  generally  intermittent.  On  the  second  day  if  a  thin  patient  was 
naked  one  could  usually  see  the  femoral  arteries  beating  at  a  distance 
of  several  yards,  and  this  was  equally  true  of  the  other  large  arteries. 
Often  this  large  movement  was  to  be  seen  in  the  vessels  in  the  neck, 
axilla,  or  groin,  and  yet  at  the  radial  or  posterior  tibial  arteries  the  pulse 
was  hardly  perceptible." 

The  sounds  of  the  heart  are  usually  clear  but  feeble.  The  blood 
contains,  as  the  disease  advances,  an  increasing  number  of 
leucocytes  of  the  polynuclear  kind,  and  at  the  later  stages 
a  short  time  before  death  large  numbers  of  plague  bacilli  may  be  de- 
tected in  the  blood  in  bubonic  cases,  while  in  septicaemic  cases  plague 
bacilli  are  in  the  blood  at  an  early  stage.  According  to  observations 
recently  made  in  Hongkong,  plague  bacilli  may  be  present  in  cases  of 
plague  during  the  initial  stage,  even  before  there  is  any  marked  rise  in 
temperature  or  before  the  disease  manifests  itself  in  the  septicaemic  or 
bubonic  form.  The  histories  of  four  cases  are  given  in  which  plague  bacilli 
are  shown  to  be  present  in  the  blood  at  a  very  early  stage.  A  fact  like 
s.  19 


The  blood. 


290  Plaxfue  in  the  Individual  [part  m 

this  may  account  for  the  severity  of  the  disease  among  the  Chinese, 
whereas  in  European  races  and  others  the  bacilhis  cannot  at  present 
readily  nuilti])ly  in  the  blood  and  selects  in  preference  the  lymphatic 
system.  In  the  Bombay  epidemic  of  1896  there  were  few  septicaemic 
cases  compared  with  the  number  in  later  epidemics,  while  in  the  South 
African  and  Australian  epidemics  septicaemic  cases  were  conspicuous 
by  their  absence. 

Case  No.  IK  F.  A.,  admitted  to  the  Government  Civil  Hospital  on  the  17th 
March,  1903,  comi)laining  of  severe  diarrhoea.  Temperature  on  admission,  normal. 
The  blood  was  examined  with  negative  results.  The  character  of  the  stool  was  loose, 
bile-stained  and  foul-smelling.  Nothing  characteristic  was  found  in  the  stool  when 
examined  microscopically.  The  number  of  .stools  on  the  day  of  admission  was  6. 
On  the  18th  4  .stools,  on  the  19th  4  stools,  and  on  the  20th  he  had  2  stools.  All  the 
stools  were  of  the  same  character  as  described.  The  temperature  was  still  noi-mal 
on  the  20th.  On  the  evening  of  the  20th  it  suddenly  rose  to  102°  F.  The  diarrhoea 
was  still  present.  On  the  21st  the  evening  temperature  was  103°  F.,  diarrhoea  still 
present.  On  the  22ud  the  temjierature  was  103°  F.,  diarrhoea  small  in  amount. 
The  l)lood  was  examined  by  the  method  recommended  by  Ross  for  malaria,  and  a 
number  of  oval,  bipolar-shaped  micro-organisms  were  found.  These  were  regarded  as 
plague  bacilli,  and  the  patient  was  removed  to  Kennedy  Town  Hospital.  Here  he 
complained  of  severe  headache  and  sleepiness.  The  tongue  was  thickly  furred,  and 
in  general  the  patient  presented  all  the  signs  of  severe  plague  infection.  No  bubo 
developed.  He  went  through  an  extremely  severe  attack  of  plague  of  the  septicaemic 
type. 

Case  No.  II.  S.  S.,  a  police  constable,  was  admitted  to  the  Government  Civil 
Hospital  on  3rd  Jmie,  1903,  complaining  of  vomiting  and  diarrhoea  of  a  day's 
duration.  On  admi.ssion  the  dejecta  were  found  to  be  watery,  bile-stained,  and  foul- 
smelling.  The  tongue  was  fin-red.  The  temperatm-e  was  100°  F.  The  blood  was 
examined  by  Ross's  method,  and  large  numbers  of  bacilli  identical  with  the  B.  pestis 
were  found.  On  the  strength  of  this,  the  patient  was  removed  to  the  Infectious 
Diseases  Hospital,  where  a  severe  and  typical  bubonic  plague  developed. 

Case  No.  III.  T.  K.,  a  Chinese  police  constable,  was  admitted  to  the  Govern- 
ment Civil  Hospital  on  the  4th  March,  1903,  complaining  of  severe  "colic,"  vomiting 
and  constant  watery  diarrhoea.  The  bowels  opened  twice  soon  after  admission,  and 
the  dejecta  were  watery  and  brownish-yellow  in  colour.  Nothing  abnormal  was  found 
in  the  stools.  The  patient  looked  very  pinched,  ill,  and  .somnolent.  The  tempera- 
ture was  99°  F. 

On  the  5th  the  temperature  was  .still  99°  F.  The  patient  was  very  sleepy  and 
dixll.  He  complained  of  severe  headache.  The  tongue  had  become  thickly  coated. 
The  diarrhoea  was  still  profuse  and  of  the  same  character.  The  blood  was  examined 
as  in  other  cases.  Bacteria  moqihologically  identical  with  the  B.  pestis  were  found. 
He  was  removed  at  once  to  Kennedy  Town  Hospital  where  he  passed  through  a 
typical  attack  of  plague  of  the  bubonic  type. 

^  A  Research  into  Epidemic  and  Epizootic  Plague.  By  Wm.  Hunter,  Government 
Bacteriologist,  Hongkong,  1904. 


CH.  xiv]  Clinical  Features  291 

Case  No.  IV.  H.  T.,  a  Chinese  coolie,  was  admitted  to  tlie  Government  Civil 
Hospital  on  the  16th  March,  1903,  complaining  of  cramps  in  the  abdomen,  headache, 
vomiting  and  diarrhoea.  On  admission  the  temperature  was  100"8°  F.,  the  tongue 
was  fo»il,  headache  was  constantly  complained  of,  and  vomiting  and  diarrhoea  con- 
tinued severe.  Xothing  abnormal  was  found  microscopically  in  the  stools.  They 
had  the  usual  naked-eye  appearance.  During  the  first  24  hours  after  admission  the 
patient  had  2-2  stools.  The  blood  was  examined  as  in  other  cases  and  organisms 
identical  with  plague  bacilli  found.  He  was  transferred  to  Kennedy  Town  Hospital 
and  deoeloped  into  a  typical  case  of  septicaemic  plague  loitli  no  bubonic  formation. 

The  appetite  varies,  being  sometimes  lost  and  at  other  times  almost 
The  digestive  I'^venous.  Intense  thirst  is,  however,  a  more  constant 
system.  symptom.     The  characteristic  condition  of  the  tongue  at 

the  different  stages  of  illness  has  already  been  referred  to.  The  soft 
palate,  fauces,  and  pharynx  are  inflamed,  the  tonsils  swollen  and  may  be 
covered  with  a  diphtheritic  coating.  Patients  may  complain  of  burning, 
dryness  and  rawness  in  the  throat.  Vomiting  preceded  by  nausea  is 
one  of  the  initial  and  most  frequent  symptoms :  occasionally  it  may 
continue  during  the  whole  acute  period  of  the  illness.  The  material 
vomited  after  the  digesta  is  a  watery  fluid,  bilious  or  dark  like  coffee- 
grounds,  and  sometimes  containing  blood. 

Constipation  is  the  usual  condition  at  the  onset  but  dian-hoea  may 
supervene  later  or  even  begin  with  the  illness.  The  evacuations  are 
usually  very  foetid  and  of  a  yellow  or  bilious  colour.  Sometimes  they 
are  dysenteric  in  character,  blood,  mucus,  and  epithelium  appearing  in 
the  stools.  Occasionally  the  diarrhoea  is  of  such  violence  as  to  suggest 
cholera.  These  intestinal  symptoms  have  been  observed  in  India  and 
China.  In  Hongkong  Wilm'  noted  that  in  20  Y„  of  the  cases  in  which 
no  external  buboes  were  formed  the  intestinal  symptoms  were  so  predo- 
minant that  the  illness  had  to  be  regarded  as  an  intestinal  affection. 
Post-mortem  examination  of  these  cases  revealed  enlargement  and 
inflammatory  changes  in  the  mesenteric  and  retro-peritoneal  glands, 
and  congestion  and  dilatation  of  the  blood  and  lymph  vessels  between 
the  affected  glands  and  the  intestine.  A  similar  but  milder  form  of 
visceral  plague  has  been  observed  in  Egypt  by  Valassopoulo-. 

Captain  Hojel-',  I.M.S.,  first  drew  attention  to  the  occurrence  in  the 
Bombay  epidemic  of  a  type  of  the  disease  in  which  abdominal  symptoms 

*  Report  on  the  Epidemic  of  Bubonic  Plague  at  Ilongkon;)  in  the  year  1896.  By  Staff- 
Surgeon  Wilm. 

2  La  Peste  d'AIexandric  en  1899.     Par  le  Dr  A.  Valassopoulo,  1901. 

•'  Report  of  tlie  Bombay  Bubonic  Plague  Research  Committee  by  Surgeon-Major  Ijyons, 
I. M.S.,  Pre.sident  of  the  Bombay  Research  Committee. 

19—2 


292  Plague  in  the  IncUvulual  [part  in 

predominated.  In  this  form  there  were  pain  and  tenderness  in  the 
epigastric  region,  pain  in  the  back,  abdominal  tension,  enlargement  of 
the  liver  and  spleen,  and  low  nervous  symptoms  similar  to  those  met 
with  in  enteric  fever,  accompanied  in  some  cases  by  the  appearance  of 
petechiae  on  the  abdomen  and  lower  part  of  the  thorax  resembling  the 
rash  of  enteric  fever.  Peyer's  patches  were  found  after  death  to  be 
slightly  raised,  oedematous  and  congested,  the  solitary  follicles  as  large 
as  a  hemp  seed,  but  there  was  no  enlargement  of  the  mesenteric  glands. 

The  urine  is  scanty,  high-coloured,  sometimes  smoky,  acid,  and  of 
•me  urinaxy  varying  degrees  of  specific  gi-avity  :  it  contains  albumen 
system.  in  the  majority  of  cases,  but  is  deficient  in  chlorides,  urea 

and  uric  acid.  In  grave  cases  there  may  be  haematuria,  or  there  may 
be  suppression  or  retention  in  the  one  case  owing  to  cessation  of  secre- 
tion, in  the  other  to  loss  of  power  of  the  functions  of  the  bladder, 
necessitating  the  employment  of  the  catheter  to  draw  off  the  urine. 
Plague  bacilli  are  present  in  some  cases ^ 

The  respiration  in  the  milder  cases  or  at  the  commencement  of 
Respiratory  those  which  become  more  serious  may  remain  unaltered 
system.  or  only  slightly  accelerated,  but  with    the  severer  forms 

and  as  the  disease  advances  the  condition  of  the  respiration  becomes 
an  important  feature  in  the  disease.  Oppression  and  tightness  across 
the  chest  are  experienced,  the  breathing  is  laborious,  the  respiration 
increased  in  frequency,  rising  to  30,  40,  50,  and  even  60  per  minute ; 
the  breathing  is  hurried  and  difficult,  the  dyspnoea  being  due  to  a 
gradually  increasing  oedema  of  the  lungs,  which  causes  much  distress  to 
the  patient.  Cough  is  generally  present.  The  sputum  is  scanty  and 
viscid  at  first  and  later  purulent,  and  in  simple  cases  without  blood. 
Auscultation  and  percussion  may  reveal  signs  of  congestion  of  the  base 
of  the  lung  and  a  more  general  catarrh,  or  of  nothing  specially  abnormal. 
In  some  cases  there  is  bronchitis  and  secondary  plague  pneumonia  as 
complications.  Clinically  there  is  nothing  to  facilitate  the  recognition 
of  secondary  pneumonia  save  a  decrease  in  the  respiratory  murmur, 
some  slight  crepitant  rales,  and  the  rapid  deterioration  in  the  condition 
of  the  patient. 

Comj)lications  and  Sequelae. 

The  complications  of  plague  are  mainly  those  coniu'ctcd  with  the 
Compiica-  respiratory  system,  such  as  bronchitis,  oedema  of  the  lungs, 

tions.  and  secondary  pneumonia ;  occasionally  pleurisy  and  pneu- 

'  A  iistrian  Report. 


CH.  xiv]  Com2)lications  and  Sequelae  293 

mothorax  may  be  met  with.  The  first  three  may  be  viewed  rather  as 
an  extension  of  the  infective  process  to  (ither  parts  of  the  system  at  a 
later  stage  of  the  disease,  and  from  this  aspect  they  form  but  a  part  of 
the  disease.  On  the  other  hand  there  are  plague  cases  with  severe 
constitutional  disturbances  without  these  respiratory  troubles.  In- 
flammatory affections  of  the  eve  are  not  infrequent  com- 
Eye  diseases.  ...  -^  . 

plications    of  plague ;    these    may    range    from    a    simple 

inflammatory  state  to  one  which  is  accompanied  by  ulceration  of  the 
cornea,  by  copious  haemorrhages,  and  in  some  cases  total  destruction  of 
the  eyesight. 

Marasmus  is  another  complication  which  occasionally  sets  in  during 
Marasmus  ^^^    period    of  convalescence.     It   usually  ends  in   death, 

and  chronic  The  patient  becomes  emaciated,  feeble  in  mind  and  body, 
unable  to  take  food,  gets  into  a  typhoid  condition,  and 
gradually  sinks.  This  state  may  be  caused  by  secondary  infections 
of  a  pyaemic  nature,  in  which  streptococci  and  staphylococci  play 
their  part,  or  by  the  intense  toxic  effect  of  the  plague  virus. 

Closely  connected  with  this  marasmus  condition  is  another  in  which 
the  disease  runs  a  chronic  course  from  the  commencement.  The  patient 
may  walk  about  notwithstanding  a  certain  amount  of  indisposition  and 
catarrh  and  yet  succumb  later  to  the  disease,  and  be  found  the  subject 
of  abscesses  containing  plague  bacilli  in  the  lungs,  liver,  and  spleen. 
This  chronic  tj^pe  closely  resembles  that  found  in  the  lower  animals. 

Indolence  of  buboes,  sinuses  connected  with  buboes  maintaining 
chronic  discharges,  and  sloughing  of  buboes  or  of  gangrenous  pustules 
can  hardly  be  classed  as  complications  though  they  materially  protract 
the  duration  of  the  illness  and  sap  the  strength  of  the  patient.  Abscesses 
and  boils  may  also  appear  in  different  parts  of  the  body  and  contribute 
to  a  retardation  of  recovery. 

In  pregnant   women   the   most   important    complication   is   that   of 

abortion,  which  in  the  majority  of  cases  is  fatal  to  mother 
Pregnancy.  .  . 

and  child.    The  danger  of  plague  under  this  condition  both 

to  mother  and  child  has  been  observed  in  every  epidemic,  ancient  and 

modern.     Exceptions  may  occur  in  which  one  or  other  or  both  may  live, 

but  they  are  rare. 

Choksy  mentions  arthritis  as  being  a  common  complication  of  cases 

of  plague  coming  under  his  observation  in  Bombay  ^     He 

xxTtf  JlTltiiS.  1*1'  • 

describes  it  as  appearing  generally  during  convalescence 

^     Report  ov  Plague  at  Arthur  Road  Hotipitdl,   Bomhai/.     By  Khan  Bahadour  N.  H. 
Choksy,  M.D. 


294  PJcufuc  in  the  ImlivkJnal  [part  m 

and  being  ushered  in  with  feverish  reaction,  the  temperature  rising 
slowly  after  having  been  low  for  a  considerable  time,  accompanied  by 
swelling  and  effusion  into  the  joints.  It  ran  a  more  or  less  acute 
course,  and  the  joints  princi])ally  involved  were  the  shoulder,  elbow, 
wrist,  knee  and  ankle.  Malaria,  bei-iberi,  cholera,  relapsing  fever, 
pulmonary  phthisis  and  syphilis  are  diseases  which  have  at  times 
conciurent  been  observed  to  coexist  with  plague.  There  is  probably 
diseases.  ^o  disease  that  may  not  accidentally  coexist  with  it,  but 

these  being  the  most  common  in  India  and  China,  where  plague  has 
been  epidemic,  the  conjunction  has  been  met  with  most  frequently. 

None  of  them  give  any  immunity  against  an  attack  of  plague.  In 
the  Hongkong  plague  epidemic  of  1902,  when  cholera  also  prevailed  as 
an  epidemic,  the  two  diseases  were  occasionally  observed  in  the  same 
person.  The  same  has  been  noted  in  India.  In  Bombay  during  the 
prevalence  of  relapsing  fever,  cases  of  plague  were  seen  in  which,  in 
addition  to  the  plague  bacillus  isolated  from  the  patient,  the  spirillum 
was  observed  in  the  blood. 

Plague  may  occur  in  a  patient  suffering  fi-om  malaria,  or  malaria 
ma}'  supervene  in  the  course  of  an  attack  of  plague.  In  these  cases  the 
malarial  parasite  may  be  found  in  the  blood,  and  the  plague  bacillus  in 
the  bubo,  in  the  sputum,  or  in  the  blood. 

Of  sequelae  the  most  important  are  affections  of  the  nervous  system. 

Aphasia,    ataxia,   and    dementia    are    the    most  common : 
Sequelae.  i  i         i  ^^         o  i  . 

happily    they    are    generally    oi    a    temporary    character 

though  they  may  be  permanent.     Parotitis  may  also  occur.     Blindness 

also   follows   some  of  the   destructive  injuries  to  the  eye,  while  the 

sloughing  associated  with  buboes  or  pustules    may  injure   important 

blood  vessels  and  cause  dangerous  haemorrhage.     Gangrene  of  the  limb 

has  also  been  observed  in  some  rare  cases. 

Second  attacks,  though  rare,  do  occur  sometimes.     It  is  now  and 

Second  again  difficult  to   distinguish   them   from  relapses  which 

attacks.  ^Ij^q  occur  occasionally.     But  this  only  happens  when  the 

second  attack  closely  follows  the  first.     Three  cases  of  second  attack 

are  recorded  as   having  occurred   in    the   first    epidemic  at  Bombay ^ 

One  was  a  European  lady  who  was  attacked  at   Hongkong  in  June, 

1894,  with  a  cervical  bubo  from  which  she  recovered  at  the  beginning 

of  August.    She  was  again  attacked  with  plague  at  Bombay  in  December, 

1896,  with  a  femoral  bubo  which  resolved  without  suppuration.     The 

second  attack  was  milder  than  the  first. 

1  Report  of  the  Health  OlHcur  for  Bombay  for  1896. 


CH.  xiv]  Second  Attacks  of  Plague  295 

The  second  case  was  that  of  a  native  in  Bombay,  the  details  of  which 
are  as  follows : — 

First  attack.  Octuber  30,  1896.  Mahomed  AUybux  Kadirally 
(age  5S),  Samuel  Street,  No.  197,  second-floor. 

3rd  day.  Left  parotid  bubo,  size  of  a  pigeon's  egg,  tender.  Pulse 
150;  respiration  44;  temperature  105.  Shivering,  delirious  (bubo 
second  day).  40  minims  of  medretine  given  and  10  minims  of  liq. 
hydrarg.  perchl.  every  2  hours.     Calomel  gr.  2  stat.     Ice  to  the  head ; 

2  powders  given. 

October  31.  Restless,  3  motions.  Temperature  103 ;  pulse  un- 
countable ;  respiration  56 ;  bubo  more  painful  and  tender.  Delirious. 
Medretine  given.  Phenacetin  and  soda  salicylate  every  2  hours,  as 
necessary. 

November  1.  Pulse  180;  respiration  44;  temperature  103'5.  De- 
lirious ;  sleep  disturbed ;  right  lung  congested.     Had  one  motion.     Had 

3  powders  and  medretine  given,  2  oz.  in  24  hours.    Mixtures,  stimulants 
and  expectorants. 

November  2.  Bubo  enlarging  and  painful ;  pulse  130 ;  respiration 
40 ;  temperature  102^2.  No  headache ;  lung  clear ;  had  one  motion. 
Treatment  same. 

November  3.  Temperature  101;  pulse  132;  respiration  33.  A 
little  better.  Medretine  given  every  2  hours,  and  ext.  carnis  and  rum 
every  4  hours. 

November  4.  Temperature  102'2 ;  pulse  144 ;  respiration  40  ;  bubo 
subsiding;  right  parotid  gland  appears  tender;  medretine  every  4  hours; 
ext.  carnis  and  rum  every  4  hours. 

November  6.  Temperature  100;  pulse  140;  respiration  40;  lungs 
a  little  congested. 

November  8.     Temperature  99;  pulse  128;  respiration  36. 

November  15.     No  fever;  bubo  suppurated;  pulse  112. 

Second  attack  or  recurrence.  December  2.  Temperature  105 ;  re- 
spiration 40 ;  pulse  144.  Very  delirious,  and  starting  in  bed.  Over 
left  parotid  gland  much  swollen  and  very  tender.  Liq.  hyd.  per 
m.  15  every  2  hours. 

December  3.     Temperature  104  ;  respiration  GO  ;  pulse  100. 

December  4^.  Temperature  104;  respiration  40  ;  pulse  102  ;  delirium 
less. 

December  5.  Temperature  100  ;  respiration  40;  pulse  100;  delirium 
less. 

December  6.     Doing  well. 


296  Pliujue  ill  tJtc  Jndiridual  [part  hi 

The  third  case  was  Mr  C.  T.,  "  an  Inspector  in  the  Bombay  Customs 
House,  a  Bania  by  caste,  age  27,  who  was  attacked  first  in  February, 
1897  ;  temperature  rising  to  105  and  a  gland  in  the  left  femoral  region 
becoming  enlarged  and  painful.  Under  treatment  the  gland  subsided 
and  the  fever  disappeared  in  a  week  ;  after  that  he  enjoyed  perfect 
health  for  nearly  two  months,  when  he  had  a  second  attack  and  the  same 
gland  again  became  enlarged  and  painful.  This  second  attack  can  be 
traced  to  his  nui'sing  and  almost  living  in  the  same  house  with  a  plague 
patient  at  Matoonga.  On  this  occasion  the  gland  suppurated  and  was 
removed  by  an  operation.  The  patient  made  a  very  slow  recovery  and 
was  finally  discharged  cured,  after  living  for  more  than  two  months  in 
the  hospital." 

These  are  all  cases  of  recovery,  but  Matignon  in  his  account  of  the 
bubonic  plague  in  Mongolia  records  the  case  of  a  man  who,  the  previous 
year,  had  been  attacked  with  very  characteristic  plague  with  buboes 
and  died  of  plague  the  following  year. 

Clot  Bey  points  out  that  Evagrius,  Yallere,  Diemerbroech,  Chenot, 
Orreus  and  Schrauel  cite  cases  of  relapses  of  plague  observed  by  them 
and  refers  to  Bertrand,  who  in  the  Marseilles  epidemic  mentions  some 
persons  who  were  attacked  three  times  daring  the  same  epidemic. 
Clot  Bey  and  his  colleagues  saw  in  Eg}^t  several  patients  who  died 
of  plague  who,  on  a  previous  occasion,  had  recovered  from  the  disease. 
Russell  out  of  4400  plague  cases  met  with  28  cases  of  reinfection ^ 

Cases  of  Plague. 

A.  B.,  a  Kaffir  boy,  admitted  to  hospital,  having  a  swelling  in  the 
Ambulant  left  groiii.     His    history  was    that    of  feeling  indisposed 

variety.  three    or    four    days    before,    having    experienced    slight 

shivering,  nausea,  and  loss  of  appetite,  after  which  a  swelling  appeared 
in  the  groin ;  next  day  the  malaise  disappeared.  Examination  in 
hospital  showed  that  the  patient  had  no  fever,  the  temperature  being 
subnormal  and  registering  97°  F.  There  was  a  bubo  about  the  size 
of  a  pigeon's  egg  immediately  above  Poupart's  ligament  in  the  left 
groin ;  the  skin  over  the  bubo  was  red  but  mobile.  The  tongue  was 
coated  with  a  white  fur  and  was  red  at  the  tip  and  edges.  The  eyes 
were  not  congested.  There  was  no  lisping  nor  slumng  of  the  speech, 
and  his  intellect  was  as  quick  as  ordinarily.  On  examination  of  the 
contents  of  the  enlarged  glands  no  bacilli  were  discoverable,  but  on 
1  A  Treatise  of  the  Plamie,  p.  190.     By  Patrick  Eussell,  M.D.,  F.R.S.,  1701. 


CH.  xiv]  Cases  of  Plague  297 

culture  of  the  contents,  characteristic  growths  of  the  plague  bacillus 
were  found.  A  guinea-pig  and  rabbit  inoculated  with  the  culture  died 
in  40  hours  from  typical  plague.  The  glands  had  been  noticed  three 
days  before  the  patient's  visit  to  hospital.  On  the  third  day  of  his 
admission  the  temperature  reached  normal,  he  appeared  in  every  way 
well,  and  the  bubo,  instead  of  suppurating,  ultimately  disappeared  by 
resolution. 

A.  B.,  Malay,  50  years,  fell  ill  on  July  9th  at  4  a.m.  in  the  Cape 
Septic  and  Town  contact   camp,  was  sent  to  hospital  at  8  a.m.,  but 

fulminating  died  on  the  way.  Thirteen  days  previously  his  son  died 
at  home  after  4  days'  illness  of  plague.  A.  B.  was  sent 
with  his  family  to  the  contact  camp  for  12  days'  observation  and  was  to 
have  been  sent  home  on  the  day  of  the  morning  on  which  he  fell  ill. 
On  the  night  of  the  8th  he  ate  his  supper,  was  apparently  well  and 
was  seen  by  the  Medical  Officer  on  the  latter's  evening  inspection. 
Some  time  after  3  a.m.  on  the  9th  he  woke  up  and  remarked  to  his 
wife  that  he  did  not  feel  well.  At  4  a.m.  he  suddenly  had  an  attack 
of  shivering  and  difficulty  of  breathing  and  fell  almost  immediately 
into  a  state  of  collapse,  dying  at  8  a.m.  The  patient  being  a  Malay 
no  post-mortem  could  be  obtained  at  the  time,  but  punctures  were 
made  into  the  spleen,  liver  and  lungs,  and  the  contents  drawn  off 
not  only  gave  smear  preparations  which  swarmed  with  plague  bacilli, 
but  also  pure  cultures  of  the  microbe.  No  buboes  could  be  detected 
by  careful  palpation  and  examination  of  the  external  parts. 

C.  1).,  Malay,  wife  of  A.  B.,  fell  ill  on  the  10th  July  at  9  p.m. 
and  died  at  2  a.m.  on  the  11th.  Patient  came  to  the  contact  camp 
with  her  husband.  When  her  husband  died  on  the  morning  of  the 
9th  July  she  felt  quite  well,  but  on  the  10th  was  depressed,  which 
was  attributed  to  her  having  lost  her  son  and  husband  by  plague.  On 
the  10th  at  9  p.m.  Dr  McCulloch,  the  medical  officer  of  the  contact 
camp,  made  his  usual  visit  and  C.  D.  was  found  in  bed.  The  daughter 
states  that  her  mother  felt  shivery,  which  she  attributed  to  grief. 
Professor  Levin  and  Dr  McCulloch  made  a  careful  examination  of 
her  condition.  There  was  no  congestion  of  the  face,  tongue  was 
normal,  temperature  98'3,  pulse  small,  soft  and  98  per  minute,  respira- 
tion slightly  hurried,  rate  28  per  minute,  lungs  and  heart  sounds 
normal.  Cervical,  axillary  and  inguinal  regions  carefully  examined 
and  no  indication  of  swollen  glands  or  buboes  observed.  The  nurse 
was  instructed  to  immediately  call  the  medical  men  if  she  noticed 
any  change  for  the  worse  in  the  condition  of  the  patient.     At  2  a.m.  of 


298  Plague  in  the  Individ ual  [part  hi 

the  11th  the  patient  suddenly  became  comatose  and  died  before  the 
arrival  of  the  doctors. 

Post-mortem  on  the  11th.  In  left  axillary  region  a  bubo  the  size 
of  a  pigeon's  egg  was  found.  The  situation  of  the  bubo  was  immediately 
behind  the  border  of  the  pectoralis  muscle  and  on  the  dead  body  was 
easily  discernible,  both  to  sight  and  touch.  Section  of  the  bubo  showed 
a  red-violet,  granular  surface.  With  pressure  there  oozed  out  a  red- 
yellow  thick  fluid.  Nearly  all  the  lymphatic  glands  in  the  body  were 
enlarged,  congested,  and  on  section  showed  a  red-violet  surface.  Pleural 
cavities  contained  about  a  pint  of  clear  yellow  fluid.  Ltings  free,  but 
oedematous.  On  section  a  great  quantity  of  reddish-yellow  aerated 
fluid  oozed  out.  Heart  normal  in  size,  valves  and  openings  free,  but 
the  margins  of  the  valves  rose-coloured  and  thickened.  Spleen  much 
enlarged,  pulp  dark  red  colour  and  friable.  Kidneys  with  sub-capsular 
ecchymoses ;  section  showed  cortical  substance  swollen,  picture  indis- 
tinct, numerous  ecchymoses  in  pelvis,  also  haemorrhage.  Liver  enlarged, 
necrotic  patches  and  fatty  infiltration  on  surface.  Stoinach  contained 
coffee-coloured  fluid  and  numerous  ecchymoses  and  haemorrhages  on 
mucous  membrane.     Blood  showed  leucocytosis. 

Bacteriolofjical  examination.  Smear  preparations  from  bubo,  glands, 
spleen,  liver  and  blood  swarming  with  plague  bacilli.  Cultures  from 
these  organs  give  pure  cultures. 

The  rapidity  of  such  cases  and  the  absence  of  buboes  or  their 
appearance  immediately  before  death  may  easily  lead  to  the  true  nature 
of  the  disease  being  overlooked.  In  some  cases  even  the  most  ex- 
perienced may  be  left  in  doubt  and  it  is  only  by  an  examination  of  the 
blood  during  life  or  by  a  post-mortem  examination  that  an  absolute 
diagnosis  can  be  made. 

James  Lombard,  coloured,  39  years,  admitted  to  hospital  on  13th 
An  atypical  June.  History.  On  morning  of  10th  became  suddenly 
^^^^'  ill  with  severe  shivering  and  vomiting  and  severe   pain 

in  the  joints,  especially  in  the  loins.  In  the  afternoon  he  observed  on 
his  face,  arms,  and  chest,  patches,  which  on  the  following  day,  the 
11th,  developed  into  small  bladders  which  covered  the  whole  body. 
On  the  12th  felt  pains  in  axilla  and  groin.  Seen  on  this  day  by  the 
Inspecting  Medical  Officer,  who  found  painful  buboes  in  axillae  and 
groins  and  a  pustular  and  papular  rash  on  forehead  and  cheeks.  Smears 
from  glands  and  pustules  contained  plague  bacilli.  The  pustules  were 
small,  irregular  in  shape,  with  no  umbilication  and  no  surrounding 
infiltration  nor  induration  of  skin. 


CH.  xiv]  Cases  of  Plague  299 

Present  state\  General  state  grave.  Patient  is  very  weak,  speech 
indistinct  and  stuttering,  conjunctivae  congested  and  injected,  lips 
very  dry,  tongue  covered  with  thick  dirty  brown  and  crusty  coating. 
Temperature  1008°  F. ;  pulse  small  and  soft,  120 ;  respiration 
hurried,  32  per  minute.  On  the  face,  arras,  legs,  on  the  front  side 
of  the  body  and  parts  of  the  back,  are  numerous  pustules  from  the  size 
of  a  pin's  head  to  a  halfpenny,  mostly  single  but  often  confluent ;  some 
limpid  and  when  pricked  a  clear  fluid  oozes  out ;  others  opaque  and  on 
puncture  a  dirty  yellow  thickish  fluid  oozes  out.  A  number  of  the 
pustules  dried  up,  leaving  crusts.  In  the  lumbar  region  on  the 
right  side  a  carbuncle  of  the  size  of  a  halfpenny  with  dark, 
raised,  undermined,  rugged  borders ;  the  bottom  of  the  ulcer  covered 
with  a  thick  purulent  dirty  yellow  matter;  another  carbuncle  on 
the  right  side  on  the  margin  of  the  lowest  rib.  In  the  cervical 
region  buboes  of  the  size  of  a  hazel-nut,  two  on  each  side ;  the  skin 
not  red  over  them  but  readily  mobile ;  the  buboes  not  painful  to 
pressure  but  painful  when  head  moved.  In  each  of  the  axillae  a  bubo 
of  the  size  of  a  pigeon's  egg,  and  of  the  same  character  as  the  cervical 
buboes.  Also  on  both  sides  epitrochlear  buboes ;  on  the  right  arm  the 
epitrochlear  very  swollen  and  very  painful  on  pressure  and  movement ; 
the  skin  very  red  and  not  mobile.  The  whole  part  very  hard  and 
much  infiltrated.  Femoral  buboes  on  both  sides  of  the  size  of  hazel- 
nuts, slightly  painful  on  pressure ;  skin  not  changed.  The  first  sound 
of  heart  indistinct,  other  sounds  normal ;  lungs  normal. 

Intravenous  injection  of  20  c.c.  Yersin  given.  A  second  dose  was 
given,  but  when  he  received  7  c.c.  patient  began  to  be  restless  and  the 
injection  was  stopped.  He  became  cyanotic  and  breathed  more  hurriedly. 
Ether  injection  was  given  subcutaneously  and  in  a  few  minutes  he 
recovered  ;  40  c.c.  Yersin  given  subcutaneously. 

14fth.  Patient  slept  a  little  during  the  night/  and  took  some 
nourishment ;  very  weak,  pulse  small,  bad,  almost  impossible  to  count. 
Temperature  100°.     40  cc.  Yersin  subcutaneously. 

15th.  General  state  very  bad,  patient  very  restless,  incontinence 
of  rectum  and  bladder,  pulse  not  countable.  Temperature  lOl'S""  in 
morning  and  104°  in  evening. 

16th.     Coma. 

11th.     Died. 

Post-mortem.    On  face,  arms,  legs,  and  most  parts  of  body  encrusted 

1  "  Bubonpesten  i  Kap,"  1901.     Reseherattelse  af  Med.  Dr  Ernest  Levin.     Stockholm, 
1902. 


300  Plcujuc  ut  the  Individual  [part  hi 

pustules.  Buboes  already  described.  Section  of  buboes  showed  a 
thick,  putty-like  pus.  Both  lungs  fixed  to  pleura  with  easily  detached 
connective  tissue.  Sub-pleural  haemorrhage.  Lower  part  of  left  lung 
covered  with  a  thin  fibrinous  e.xudation.  On  section  of  lower  part  of 
left  lung,  small  granular  elevated  patches  of  a  rosy  colour  with  a 
distinct  slightly  depressed  centre.  In  other  part  of  left  lung  a  few 
similar  patches  noticed. 

Lower  lobe  of  right  lung  had  also  a  fibrinous  covering.  Section  of 
right  lung  showed  a  grey-red,  elevated,  granular  surface  of  an  hepatic 
appearance,  and  on  pressure  there  oozed  out  a  dirty  red-yellow  fluid 
devoid  of  air. 

In  other  parts  of  lung  similar  patches  as  in  left.  At  the  base  of 
the  heart  several  sub-pericardial  ecchymoses.  Heart  slightly  enlarged ; 
valve  openings  normal.  In  the  muscular  tissue  of  heart  greyish-yellow 
patches.  Sj)leen  not  enlarged,  dark  red ;  consistence  soft  and  friable. 
Kidneys  with  sub-capsular  ecchymosis. 

Section  of  kidney.  The  cortical  substance  swollen  and  thickened 
and  not  distinct.  Liver  enlarged  with  fatty  infiltration.  Stomach  and 
intestines  normal. 

Bacteriological  examination.  Pus  from  pustules  on  14th  June 
exhibited  in  direct  preparation  a  few  typical  bacilli.  In  culture  only 
staphylococci.  Axillary  bubo,  femoral  bubo,  heart  blood  and  lungs 
showed  no  bacilli  in  either  smear  preparations  or  in  cultures. 

There  are  two  varieties  of  pneumonic  plague.  One  is  primary  in  its 
Plague  character,  and  the  other  is  secondary  or  symptomatic, 

pneumonia.  Primary  plague  pneumonia  is  a   type  of  the  disease 

in  which  the  primary  localisation  of  the  plague  bacillus  takes  place  in 
some  of  the  lobules  of  the  lungs  instead  of  in  the  glands  of  the  groin, 
arm-pit,  or  neck  or  other  glands  of  the  lymphatic  system. 

Secondary  pneumonia,  on  the  other  hand,  develops  in  the  course  of 
other  ty]Des  of  plague  and  is  due  to  a  secondary  infection  which  has 
reached  the  lungs  metastatically  through  the  circulation  or  lymphatic 
vessels  from  some  other  already  infected  centre  of  the  body,  or  has, 
as  in  the  case  of  tonsillar  plague,  been  inhaled  into  the  lungs. 

The  clinical  aspects  of  primary  pneumonic  plague  are  not  very 
distinctive,  and  were  it  not  for  the  discovery  of  plague  bacilli  in  the 
sputum  this  type  of  plague  may  easily  be  mistaken  for  broncho- 
pneumonia.    Surgeon-Major  Childe's  description^  of  the   symptoms  of 

'  Report  by  Surgeon-Major  Lj-ons,  I.;SI.S.,  President  of  the  Plague  Research  Com- 
mittee. 


CH.  xiv]  Cases  of  Plague  301 

the  illness  of  Dr  Manser  of  Bombay  and  of  the  nurse  who  attended 
him,  both  of  whom  were  attacked  with  plague,  will,  with  Dr  Poch's 
description  of  Dr  Mueller's  illness,  illustrate  this  type  of  the  disease. 

"  With  regard  to  the  clinical  symptoms  of  these  cases,  it  fell  to  me  to 
Dr  Manser's  attend  on  the  late  Dr  Manser,  and  as  he  died  of  this  form 
illness.  ^f  plague  I  will  mention  a  few  facts  about  his  case.     He 

was  in  his  usual  health  on  January  2nd,  and  had  a  sudden  rigor  in  the 
morning  and  felt  fever  coming  on.  During  the  day  a  bad  headache 
developed,  he  felt  nausea  and  vomited  several  times,  and  he  had  pains 
and  a  tired  feeling  in  his  limbs ;  his  tongue  remained  clean  and  moist, 
and  his  skin  was  slightly  moist.  At  2  p.m.,  temperature  108'4,  pulse  116, 
respiration  25,  and  there  were  but  slight  variations  during  the  day.  On 
January  3rd,  had  passed  a  bad  night  and  felt  worse,  and  all  the 
symptoms  persisted,  except  the  aching  in  the  limbs,  and  he  felt  very  ill. 
The  temperature  remained  between  103'5  and  104"5,  pulse  about  110, 
and  the  respirations  about  23  throughout  the  day.  During  the  after- 
noon he  felt  some  pain  at  the  lower  part  of  the  left  axilla  just 
underneath  the  anterior  fold,  but  there  was  no  glandular  enlargement  or 
pain  in  the  glands  anywhere.  On  January  4th,  had  passed  a  bad  night 
and  felt  very  ill,  temperature  104*6,  pulse  113,  respiration  25,  tongue 
still  moist,  with  a  little  fur  behind,  and  no  sordes  about  the  lips  and 
teeth,  other  symptoms  as  before.  During  the  night  he  began  to  cough 
and  brought  up  some  watery  sero-mucous  fluid,  slightly  blood-tinged, 
and  the  pain  remained  in  the  same  place,  only  more  diffused  now,  being 
felt  over  an  area  of  a  square  inch.  At  this  part  some  moist  sounds 
could  be  heard  like  early  pneumonia,  and  they  could  also  be  heard  just 
below  the  left  clavicle ;  the  rest  of  the  lungs  and  other  organs  appeared 
to  be  normal,  as  did  the  lymphatic  glands.  Patient  considered  that  he 
had  pneumonia,  but  the  symptoms  were  not  like  ordinary  pneumonia. 
For  the  onset  was  different,  the  condition  of  the  mouth  and  tongue 
different,  there  was  no  dyspnoea  or  pneumonic  disproportion  of  pulse  and 
respiration,  and  the  sputum  was  not  at  all  like  rusty  sputum ;  for  it  was 
loose  and  free,  coming  up  with  the  slightest  cough,  it  was  watery,  looking 
more  like  serum  than  mucus,  and  it  was  slightly  pink,  not  rusty  yellow 
at  all.  Also  there  was  the  striking  fact  that  the  patient's  general 
condition  was  far  worse  than  could  be  explained  by  the  small  amount  of 
lung-disease  present.  So  I  examined  the  sputum  under  the  microscope, 
and  found  it  full  of  bacilli  looking  like  those  of  plague,  and  cultures 
were  made  from  which  a  pure  growth  of  the  plague  bacillus  was 
obtained.     During   4th  and  5th,  patient   became   steadily   worse,   his 


'302  Plafjvf  in  titr  Individual  [part  hi 

temperature  remained  about  104,  and  his  expectoration  became  more 
profuse ;  the  moist  sounds  were  heard  over  a  larger  area,  as  well  as 
slightly  at  the  bases ;  the  respirations  increased  to  35,  and  then  to  45, 
and  the  pulse  to  120  and  135;  and  he  ultimately  died  early  on 
January  6th. 

"  There  is  also  the  case  of  the  nurse  who  attended  him,  who  un- 
fortunately died  of  a  similar  form  of  plague.  In  brief  she  became  ill  on 
the  evening  of  January  7th,  and  showed  symptoms  of  pneumonia  on 
January  8th.  She  rapidly  became  worse  and  died  on  the  10th,  but  her 
sputum  was  not  nearly  so  profuse  as  in  the  former  case,  and  symptoms 
of  exhaustion  came  on  much  earlier.  She  also  had  no  glandular  pain  or 
enlargement  whatever  and  bacteriologically  her  sputum  was  exactly  as 
described  above.  Other  cases  were  met  with  in  which  besides  plague- 
pneumonia,  there  was  also  general  enlargement  of  the  glands, — plague- 
septicaemia  ;  and  clinically  it  was  found  that  either  the  pneumonia  was 
primary,  and  the  glandular  enlargement  secondary,  or  that  the  disease 
first  showed  itself  in  the  glands  and  later  on  in  the  lungs ;  and  whilst 
some  of  the  latter  recovered,  the  former  were  usually  rapidly  fatal. 
Also  the  sputum  was  not  always  as  has  been  described  above,  for  in  some 
cases  the  presence  of  blood  in  it  was  a  marked  feature,  and  it  was  either 
moderate  or  abundant  in  quantit^^  These  pneumonic  forms  of  plague 
are  highly  infectious  and  probably  take  a  large  share  in  the  spread  of 
the  disease ;  for  in  these  cases  the  patient's  sputum  is  practically 
a  virulent  pure  culture  of  the  plague  bacillus,  and  as  there  is  reason  to 
believe  that  many  of  the  cases  are  not  recognised  as  plague  at  all,  pre- 
cautions are  not  taken  by  the  patients'  friends,  and  the  dangerous  nature 
of  the  disease  is  not  appreciated." 

Dr  Poch'  begins  by  referring  to  the  circumstances  by  which 
Dr  MueUer's  l^^  Mueller  contracted  the  infection.  On  the  15th  Oct. 
illness.  \^m,    Franz    Barisch,    the    servant    of   the    pathological 

institution  in  Vienna,  who  had  been  assigned  to  the  assistance  of 
Albrecht  and  Ghon  to  render  them  service  in  their  investigations  on 
plague,  fell  ill  with  the  symptoms  of  a  commencing  pneumonia.  His 
sputum  was  examined  by  Drs  Ghon  and  Albrecht  on  account  of  their 
suspicions  being  aroused  by  his  previous  work,  and  this  examination 
awakened  a  suspicion  of  infection  by  plague  bacilli. 

Dr  ]\Iucller  who  was  called  to  examine  him  clinically  had  him 
immediately  removed  with  all  precautions  to  an  isolation  ward  of  the 

1   Ueber  die  BeulenpesI  in  litmihai/  im  Jahre  1897.     Vol.  i.    Anhang. . 


CH.  xiv]  Cases  of  Plague  303 

Vienna  General  Hospital.  At  the  same  time  Dr  Ghon  })ersonally 
superintended  the  disinfection  of  Barisch's  home. 

Though  Dr  Mueller  during  the  first  days  of  the  illness  could  not 
with  certainty  confirm  a  diagnosis  of  infection  with  plague  bacilli  he 
adopted  all  precautionary  sanitary  measures  and  impressed  on  the  two 
nurses  the  greatest  caution.  He  bestowed  much  attention  and  care  on 
the  patient  and  did  not  hesitate  to  examine  him  repeatedly  and 
minutely.     It  was  in  this  service  that  he  contracted  plague. 

On  the  18th  of  October,  on  the  4th  day  of  the  disease,  the  servant 
died  of  pneumonic  plague.  This  diagnosis  was  fully  confirmed  bacterio- 
logically  and  clinically. 

On  the  20th  of  October  one  of  Barisch's  nurses,  who  in  the  meantime 
had  been  strictly  isolated,  became  feverish.  On  this  account  both  of 
them  were  taken  to  the  isolation  ward  of  the  Emperor  Franz  Joseph 
Hospital,  whither  Dr  Mueller  also  betook  himself,  having  of  his  own  free 
will  offered  himself  for  the  treatment  of  the  sick  nurse. 

On  his  arrival  in  the  hospital  Dr  Mueller  was  seemingly  quite  well, 
but  on  the  same  evening  he  felt  continually  cold,  and  walked  up  and  down 
the  room  shivering  and  rubbing  his  hands,  although  the  room  was  well 
heated.  He  complained  of  feeling  low-spirited  and  had  crural  pains. 
He  also  coughed,  but  without  expectoration.  He  attributed  this  indis- 
position to  fatigue  and  a  chill.  The  nurse  attending  on  him  formed 
the  impression  that  he  was  feverish  and  begged  him  to  take  his 
temperature.  This,  however,  he  did  not  do.  He  left  his  supper  almost 
untouched  and  went  to  bed  at  8  o'clock.  He  slept  quietly  and 
soundly. 

On  the  21st  of  October  Dr  Mueller  paid  his  morning  visit  to  Barisch's 
two  nurses.  He  looked  very  pale,  felt  languid  and  lay  down  again 
at  9  a.m.  in  order  to  rest.  At  this  time  his  pulse  was  110,  he  coughed 
a  great  deal  but  brought  nothing  up.  About  midday  he  got  up  again, 
but  had  to  go  back  to  bed  shortly  after.  His  temperature  was  now 
taken  for  the  first  time.     It  was  38'2  C. 

He  now  began  to  expectorate ;  it  was  a  reddish  and  thin  fluid. 
Dr  Kretz  who  undertook  the  examination  of  the  sputum  confirmed  the 
existence  of  plague  bacilli.  Although  it  was  sought  to  deceive 
Dr  Mueller  as  to  the  results  of  this  examination,  he  himself  confirmed 
the  diagnosis  of  pneumonic  plague  from  his  symptoms  and  held  fast  to 
his  opinion.  The  pulse  was  small,  tense,  the  highest  frequency  120. 
At  2  p.m.  his  respiration  was  accelerated  to  40  and  regular.  The  fits  of 
coughing   became   more    frequent    and   copious   reddish    sputum   was 


304 


Playne  In  the  I nd'n'idual 


[part  III 


expectorated.  The  i)atient  did  not  complain  of  pain.  The  fever  at 
6  p.m.  reached  its  highest  point,  408°  C.  Consciousness  was  maintained. 
Digitalis  and  alcohol  were  given.  He  was  very  thirsty.  He  decidedly 
refused  an  injection  of  plague  serum. 

In  the  course  of  the  afternoon  he  had  two  Huid,  not  bloody  stools. 
He  had  a  fairly  good  night,  woke  a  few  times,  was  delirious  a  short  time ; 
soon,  however,  fell  asleep  again. 

On  the  morning  of  October  22nd  the  conjunctivae  of  the  patient  were 
much  reddened.    He  was  unconscious  and  noisy  delirium  set  in.    Speech 

Dr    MUELLKK 


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was  woolly  and  in<listinct.  Large  cpuxntities  of  ri'ddish  Huid  s})utum 
were  brought  u\)  in  frequent  short  fits  of  coughing.  On  this  day 
Dr  Mueller  took  no  solid  nourishment.  He  had  a  second  dose  of 
digitalis  and  a  good   quantity  of  alcohol.     In   the  afternoon  he  com- 


CH.  xi\  ]  Cams  of  Plague  305 

plained  of  pain  in  his  chest  and  asked  for  morphia.  He,  however, 
hardly  took  a  third  of  what  was  ordered  him,  the  pains  having  in  the 
meantime  diminished.  At  (J  p.m.  the  respiration  was  quickened  and 
very  difficult,  frequency  59.  Cyanosis  set  in.  The  fits  of  coughing 
became  more  frequent  still  and  rattling  with  a  quantity  of  bloody 
expectoration.  There  were  no  skin  haemorrhages  or  glandular 
swellings.  In  the  afternoon  he  had  4  thin,  not  bloody  stools,  with 
accompanying  pains.  Consciousness  was  dulled.  When  the  thermo- 
meter was  applied  Dr  Mueller  awoke  out  of  his  somnolent  condition 
and  began  to  count  pulse  and  respiration.  He  made  frequent  mistakes, 
and  began  to  count  anew  until  he  came  to  a  result.  At  10  p.m.  the 
temperature  sank  to  37 '8  and  fin-  a  short  time  consciousness  was  again 
clearer.     Then  again  great  restlessness  and  delirium  set  in. 

Oil  the  23?yZ  of  October  at  1  a.m.  Dr  Mueller  stood  up  and  walked 
up  and  down  the  room  with  help,  then  he  lay  down  again  and  went  to 
sleep.  Later  he  woke  again  and  passed  urine.  There  were  never 
involuntary  motions  or  urinating. 

At  4<  a.m.  the  temperature  was  38°  C,  breathing  was  difficult,  cyanosis 
had  increased. 

At  4.15  a.m.  rattling  in  the  throat  began,  bloody  mucus  poured  in 
quantities  from  the  mouth  and  at  4.30  a.m.  death  set  in. 


20 


/ 


CHAPTER   XV. 

DIAGNOSIS   AND   PROGNOSIS. 

In  the  majority  of  cases  there  is  no  difficulty  in  the  diagnosis  of 

plague.      The    sudden    onset,    the    severe    headache,    the 

Diagnosis  piddiness,  the  high  fever  of  a   remittent  type,  with  hot 

generally  not  .  .  ^  jt   ' 

difficult  in  a       dry  skin,  the  drawn  and  anxious  face,  the  red  and  con- 

of  pTague^^^  gested  eyes  without  photophobia,  the  flushed  countenance, 
the  stuttering,  thick  and  indistinct  speech  like  that  of  a 
drunken  man,  the  coated  tongue  red  at  the  ti})  and  edges,  the  staggering 
gait,  the  incoordination  of  the  voluntary  muscles,  the  desire  to  wander 
about,  the  quick  feeble  pulse,  the  hurried  respiration,  the  rapid  develop- 
ment of  cerebral  sym])t(>ms,  the  heavy  drowsy  and  stupid  mental  condition, 
and  the  formation  of  a  bubo  or  buboes  in  the  region  of  the  lymphatic 
glands  present  such  a  clear  picture  of  plague  that  the  disease  may  be 
readily  recognised  by  a  careful  observer  who  is  on  the  alert  as  to  the 
possible  occurrence  of  plague. 

The  bubo  which  is  the  most  characteristic  symptom  may  at  the  time 
of  examination  not  be  in  evidence.  The  bubo  generally  appears  within 
24  h(jurs  but  may  be  delayed  till  the  third,  fourth,  or  fifth  day  and  in 
some  exceptional  cases  even  longer,  the  other  sjanptoms  being  well 
defined.  In  some  cases  the  affected  glands  do  not  form  buboes,  but 
are  usually  recognisable  from  their  exquisite  tenderness  when  touched ; 
in  other  cases  they  are  deeply  situated  and  it  is  only  by  strong  pressure 
over  the  parts  that  they  are  detected.  When  the  clinical  symptoms 
indicate  plague,  and  yet  there  is  no  bubo  in  the  groin,  arm-pit  or  neck, 
a  careful  examination  of  the  abdomen  often  reveals  a  bubo  in  the  iliac 
or  lumbar  region. 

In  milder  cases  when  some  of  the  symptoms  are  absent,  and  es- 
])ecially  when  consciousness  and  a  clear  intellect  obscure  the  character 
of  the  disease,  the  ])ulse  is  of  valuable  assistance  as  a  guide  to  diagnosis. 


CH.  xv]  Diagnosis  and  Prognosis  307 

It  is  rapid  and  feeble,  and  out  of  all  })roportion  to  the  condition  of  the 
patient. 

Before  this  pandemic  the  diagnosis  of  plague  had  to  rest  on  the 
clinical  symptoms,  but  now  to  these  is  added  the  bacteriological  test. 
Bacterio-  ^J  puncturing  the  bubo  even  at  its  earliest  stage  a  small 

logical  test.  quantity  of  the  gelatinous  contents  can  be  sucked  out  with 
a  sterilised  glass  pipette  guarded  at  the  mouth  end  by  sterilised  cotton 
wool.  If  the  contents  so  obtained  are  then  spread  out  on  a  glass  slide 
or  cover-glass,  gently  heated  as  in  the  ordinary  preparation  of  a  micro- 
scopical specimen,  coloured  with  carbol  fuchsin  or  gentian  violet,  and 
then  examined  by  a  -^^  oil  immersion  lens,  the  field  will  be  seen  to  be 
covered  with  cocco-bacilli  or  diplo-bacteria,  large  numbers  of  them  being 
more  deeply  stained  at  the  ends  than  in  the  centre.  No  other  disease 
with  swollen  lymphatic  glands  presents  microbes  such  as  these.  Their 
presence  is  sufficient  to  arouse  the  greatest  suspicion  at  any  time,  and 
the  material  ought  to  be  taken  at  once  to  a  laboratory  where  the  bacilli 
can  be  cultivated  and  the  confirmatory  tests  applied.  When  plague  is 
known  to  prevail  in  a  country  the  discovery  of  bacilli  by  microscopical 
examination,  combined  with  the  clinical  features,  is  sufficient  to  make 
the  diagnosis  of  plague  a  certainty. 

In  cases  in  which  the  bubo  has  suppurated  the  pus  only  exceptionally 
contains  plague  bacilli  and  the  diagnosis  must  then  rest  on  the  clinical 
features  considered  as  a  whole,  together  with  the  specific  agglutination 
test  of  the  blood. 

The  serum  test,  however,  is  one  not  of  much  practical  utility  owing 
The  serum  ^o  the  fact  that  frequently  no  reaction  is  given  with  the 

test.  blood  of  patients  convalescing  from  plague,  and  to  the 

further  fact  that  in  an  ordinary  culture  of  plague  bacilli  the  microbes 
are  often  so  massed  together  that  an  extra  clumping  by  the  aggluti- 
nating process  of  the  serum  is  difficult  to  recognise.  The  Indian  Plague 
Commission'  in  summing  up  their  experience  on  this  subject  came  to 
the  conclusion  that  "  no  practical  value  attaches  to  the  method  of  serum 
diagnosis  in  the  case  of  plague." 

On  the  other  hand^  Cairns  in  the  Glasgow  epidemic  found  by  a 
series  of  careful  experiments  that  if  agar  cultures  are  emulsified  with 
sterile  0'75"/o  salt  solution  a  homogeneous  emulsion  of  the  plague 
bacillus   is    obtainable   and   that   the   sedimentation    test    under   these 

1  Report  of  the  Indian  Phujue  Commisaion,  Vol.  v.  chap.  iii.  p.  68. 

-  Report  on  certain  Cases  of  Plague  in  Glasgow  in  1900.  By  the  Medical  Ollicer  uf 
Health. 

20—2 


308  Flafjm  in  the  IndlvUhial  [part  hi 

conditions   gave    good    results    and   that    the   diagnostic   vahie   of  the 

reaction  became  more  apparent  during  and  subsequently  to  the  stage 

(tf  convalescence  when  the  possibility  of  a  bacteriological  diagnosis  is 

more  or  less  remote. 

The   absence   of  lymphangitis  connected  with   the  bubo  serves  as 

„^     ^  a  diagnostic  point  in  favour  of  its  being  a  plague  bubo 

The  absence  »  ^  .  i  i 

of  lymphan-        owing  to  the  fact  that  the  microbe  of  plague  very  seldom 

^^  ^^'  leaves  any  trace  of  local  reaction  at  its  point  of  entry.     In 

cases  in  which  a  pustule  does  appear  at  what  may  be  considered  the 

point  of  entry,  bacteriological  examination  shows  in   the  case  of  the 

plague  pustule    plague   bacilli  which   at    once   differentiate   it  from  a 

malignant  pustule  or  from   a   septicaemic  pustule  with  lymphangitis, 

the  cultures  of  which  will  show^  streptococci. 

The  difficulty  of  clinical  diagnosis  arises  chiefly  in  recognising  the 

Chief  diffl-  several  forms  and  types  which  the  disease  assumes,  and 

cuity  arises        more   particularly   is    this    the    case   with   the    ambulant, 

from  the  Pro-  .  .  :;  .  ■  ^  ^     ^ 

tean  charac-       se})ticaemic,    and    pneumonic    types    without    buboes,   as 

ter  of  plague.  ^^,g}j  .^^g  ysnth  the  tonsillar  form  associated  with  cervical 
buboes. 

If  there  is  no  suspicion  of  plague  and  no  bacteriological  examination 
made,  the  clinical  features  and  even  the  post-mortem  appearances  may 
be  attributed  to  some  other  disease.  The  events  wdiich  occurred  at 
Paraguay  in  connection  with  plague  illustrate  that  which  may  occur 
under  any  circumstances  in  which  plague  has  never  been  seen  before. 

The  first  case  at  Asuncion  showed  a  glandular  enlargement  and  some 
obscure  lung  affection,  death  being  attributed  to  disease  of  the  lungs. 
The  second  case  showed  symptoms  believed  by  one  medical  man  to  be 
those  of  acute  gastritis  and  by  another  to  be  those  of  a  general  affection, 
possibly  yellow  fever.  It  was  because  of  this  latter  opinion  that  several 
distinguished  physicians  were  sent  to  attend  the  post-mortem  examina- 
tion in  order  to  decide  the  question,  as  it  was  of  importance  that  if  the 
disease  were  yellow  fever,  precautionary  measures  to  prevent  its  spread 
should  be  immediately  adopted.  The  necrops}-  revealed  general  con- 
gestion of  the  internal  organs,  haemorrhagic  swellings  in  the  spleen,  an 
enlarged  liver,  and  an  acute  gastro-enteritis.  The  conclusion  arrived  at 
was  that  it  was  not  a  case  of  yellow  fever.  No  one,  however,  suspected 
plague,  which  was  unknown  in  America  and  which  w-as  not  known  to  be 
nearer  than  Egy])t.  The  third  case,  which  came  off  the  same  ship,  was 
that  of  a  sailor  who  went  to  a  small  village  at  some  distance  from 
Asuncion.      He  was  taken  ill   there  and  five  months  afterwards,  on  his 


CH.  xv]  Diagnosis  and  Prognosis  309 

return  to  Asuncion  he  was  found  on  examination  to  have  the  signs  still 
on  him  of  buboes  characteristic  of  plague.  The  three  cases  are 
excellent  examples  of  the  uncertainty  of  the  diagnosis  of  plague  when 
no  suspicion  of  plague  is  in  the  mind  of  the  medical  man.  The  true 
significance  of  these  cases  in  Asuncion  was  not  realised  until  five  months 
afterwards  and  then  only  when  a  new  disease,  distinguished  by  symptoms 
resembling  typhus  fever,  meningitis,  and  pneumonia,  and  frequently 
accompanied  by  glandular  enlargements  in  the  groin,  axilla,  or  neck,  had 
appeared  and  prevailed,  first  of  all  in  a  sporadic  form  in  the  town  for 
about  two  months,  and  later  in  an  epidemic  fijrm  in  the  barracks.  Only 
gradually  was  the  suspicion  aroused  that  the  disease  might  be  plague, 
and  once  that  suspicion  became  general,  the  discovery,  isolation,  and 
culture  of  the  plague  bacillus,  the  classical  symptoms  of  plague  which 
many  of  the  cases  presented,  and  the  no  less  characteristic  anatomical 
features  which  were  observed  at  the  post-mortem  examination  cleared 
away  every  possible  doubt.  In  an  investigation  which  followed  this 
discovery  no  difficulty  was  experienced  in  tracing  the  new  disease  back 
to  its  commencement ;  nor  was  there  any  difficulty  in  recognising  the 
symptoms  and  post-mortem  appearances,  which  had  perplexed  the 
medical  men  six  months  previously,  as  belonging  to  true  cases  of 
plague. 

The  ambulant  form  is  apt  to  be  overlooked  from  the  mildness  of  the 
Ambulant  symptoms.     Slight  fever,  malaise,  headache  and  congested 

plague.  gygy  have  nothing  characteristic  about  them  to  indicate 

such  a  grave  disease  as  plague,  and  a  glandular  swelling  may  occur 
under  other  circumstances,  such  as  syphilis,  mumps,  and  abrasions, 
wounds,  or  ulcers  with  sympathetic  glands.  It  is  only  possible  by 
a  process  of  careful  exclusion  combined  with  a  history  of  the  case  and 
a  knowledge  of  plague  being  in  the  neighbourhood,  that  suspicion  may 
be  aroused,  and  it  is  only  by  bacteriological  methods  that  a  reliable  con- 
firmation of  the  suspicion  can  be  obtained.  Microscopical  examination 
is  not  sufficient,  but  must  be  supplemented  by  cultures  of  the  contents 
of  the  bubo  and  by  inoculation  of  animals.  The  inoculations  are 
performed  in  one  set  of  animals  with  the  pure  cultures  obtained  and  in 
another  set  by  the  crude  contents  of  the  bubo.  The  latter  method, 
however,  is  not  a  reliable  one  for  isolating  the  plague  microbe  if  mixed 
with  other  bacteria.  In  attempting  cultures  from  the  blood  the  best 
results  are  obtained  when  comparatively  large  quantities  such  as  1  c.c. 
or  2  c.c.  are  employed.  The  medical  practitioner  has  seldom  the  time  or 
the  apparatus  for  a  complete  bacteriological  examination,  which  in  cases 


310  Plague  in  the  fnflividnal  [part  m 

of  this  kind  should  be  delegated  to  the  bacteriologist  of  the  local 
authority. 

The  illness  is  sometimes  of  a  short  duration  and  sometimes  of 
a  chronic  nature,  and  some  of  the  symptoms  may  be  absent.  Fre- 
quently towards  the  termination  of  an  epidemic  diffuse  swellings  over 
the  cervical  and  parotid  glands  with  or  without  fever,  together  with 
quick  pulse,  drawn  face  and  hesitating  speech,  occur  in  persons  who  have 
been  associated  with  plague  persons  or  plague  houses.  These  cases 
occurring  at  the  end  of  an  epidemic  do  not  present  the  same  difficulties 
as  ambulant  cases  at  the  commencement  of  an  epidemic.  Such  cases 
were  observed  in  Bombay  and  in  Cape  Town. 

In  the  fulminating,  septic  and  pneumonic  types  of  the  disease,  in 
which  no  buboes  may  be  found,  an  examination  of  the  blood  and  sputum 
for  the  characteristic  bacilli  is  the  chief  diagnostic  test.  In  fact  in  all 
cases  that  are  clinically  obscure  bacteriological  examination  is  needed 
to  elucidate  them. 

In  the  septic  type  the  bacilli  early  invade  the  blood  and  the  patient 

is  prostrated  with  the  intensity  and  amount  of  the  poison 
Septic  type.  .  i  •  i  •  i 

which  has  penetrated  into  the  system.    Besides  the  common 

symptoms  belonging  to  all  forms  of  plague  this  type  is  characterised  by 
a  pallid  and  a])athetic  expression  and  a  rapid  setting  in  of  extreme 
nervous  jirostration,  delirium,  coma  and  death,  the  patient  often  suffering 
from  haemorrhages  from  the  nose,  kidneys,  or  bowels.  In  the  less  rapid 
septicaemic  cases,  besides  the  detection  of  plague  bacilli  in  the  blood, 
plague  bacilli  Avill  be  found  occasionally  in  the  urine,  and  in  the 
expectoration  of  those  with  hyjjostasis  of  the  lungs  and  of  those  with 
secondary  pneumonia.  It  is  a  type  of  disease  which  is  very  apt  to  be 
overlooked.  The  absence  of  buboes,  the  normal  or  subnormal  tempera- 
ture in  the  morning  in  some  cases  and  the  rise  of  temperature  to  not 
more  than  100''  or  101^  are  not  symptoms  which  readily  raise  suspicion 
as  to  plague.  There  are  other  cases  in  which  a  sharp  attack  of  diarrhoea 
is  the  most  evident  symptom.  There  are  other  cases  again  in  which  the 
patient  is  attacked  with  fever  of  a  remittent  type  without  showing  the 
pulse,  tongue,  or  characteristic  appearance  of  a  plague  patient,  and  the 
bubo  if  any  appears  is  delayed  to  the  7th  or  8th  day.  Yet  any  of  these 
may  die  suddenly  and  it  is  only  the  sudden  death  which  attracts 
attention. 

Pneumonic  ])lague  is  specially  apt  to  be  overlooked,  its  ])hysical  signs 
Pneumonic  being  often  ill-defined.  During  an  epidemic  of  plague 
plague.  cases    of    pneumonia    should    be    viewed    with    suspicion 


cii.  xv]  Diagnosis  and  Prognosis  311 

especially  if  associated  with  enlargement  of  the  spleen.  In  the 
pneumonic  type  the  bacilli  are  to  be  detected  in  the  sputum,  the  disease 
localising  itself  first  in  the  lungs.  The  symptoms  are  those  of  a 
broncho-pneumonia  with  much  greater  prostration.  Dyspnoea,  cough 
and  expectoration  of  a  watery  fluid  tinged  with  blood  are  the  chief 
clinical  features.  The  absence  of  any  well-marked  and  special  physical 
signs  of  serious  lung  mischief  which  would  account  for  the  gravity 
and  rapidity  of  development  of  the  general  symptoms  is  a  feature  that 
should  raise  suspicions  as  to  the  possibility  of  primary  plague  pneumonia. 
The  sputum  of  all  respiratory  affections  during  an  epidemic  of  plague 
should  be  examined  bacteriologically  and  tested  by  inoculation  on 
animals  for  plague  bacilli. 

The  difficulty  connected  with  the  diagnosis  of  pneumonic  plague 
will  be  seen  from  the  following  case  recorded  by  Dr  A.  C.  F.  Halford'  of 
Brisbane  which  was  provisionally  diagnosed  as  measles. 

"  Aged  30,  living  at  South  Brisbane,  was  admitted  to  the  Brisbane 
General  Hospital  on  the  4th  June,  1901.  The  patient  was  quite  well 
until  the  28th  May,  1901,  Avhen  he  complained  of  headache  and  feverish- 
ness.  Next  day  he  complained  also  of  chilliness,  headache,  feverishness 
and  weakness.  He  continued  in  the  same  condition  until  the  1st  June, 
when  he  got  up  and  went  for  a  walk,  feeling  better.  He  had  on  some 
previous  occasions  suffered  from  fever  contracted  in  New  Guinea,  and 
put  his  present  illness  down  to  the  same  cause.  He  got  worse  again 
that  night,  and  remained  in  bed  all  the  next  day.  On  the  3rd  he  com- 
plained of  pains  all  over  his  body.  On  the  4th  the  pains  were  more 
severe  and  the  breathing  became  rapid  and  his  voice  husky.  He  Avas 
seen  by  a  medical  man  who  noticed  a  rash  like  that  of  measles  about 
the  body,  but  more  especially  marked  on  the  arms.  The  eyes  were 
injected  and  the  patient  had  a  slight  cough.  A  provisional  diagnosis  of 
measles  was  made,  and  the  patient  removed  to  the  General  Hospital. 
On  admission  his  temperature  was  103,  pulse  140,  and  respirations  60. 
No  bronchial  breathing  could  be  detected,  but  there  were  moist  sounds 
from  base  to  apex  on  both  sides.  He  only  lived  a  few  hours  in  the 
hospital  but  he  had  no  serum,  and  at  the  post-mortem  examination  the 
whole  of  both  lungs  were  found  extensively  consolidated.  The  bronchial 
glands  were  enlarged  and  blackened  with  haemorrhagic  inflammation. 
No  enlarged  glands  were  found  anywhere  else,  nor  was  there  any  other 
macroscopic  changes  noted  in  the  other  organs.     Smear  preparations 

'  Report  on  117  Cases  of  Plague  occarriinj  in  Brisbane.     By  the  Medical  Officer  to  the 
Metropolitan  Joint  Board  for  the  Prevention  of  Epidemic  Disease,  Brisbane,  1902. 


312  Plarfue  in  fltr   hnlirhhial  [part  hi 

from  the  affected  lungs  .showed  presence  of  innumerable  plague  bacilli 
apparently  in  pure  culture.  An  infected  rat  was  found  at  the  place  of 
his  employment." 

In  those  cases  of  pneumonic  plague  in  which  there  is  only  slight 
cough  and  no  sputum,  it  is  impossible  at  an  early  stage  of  an  epidemic 
to  form  more  than  a  suspicion  until  either  the  further  development  of 
lung  symptoms  with  expectoration  gives  an  opportunity  of  detecting  and 
isolating  the  plague  bacillus,  or  the  death  of  the  patient  allows  of 
a  post-mortem  examination.  During  an  epidemic  it  is  safer  to  class 
all  doubtful  cases  as  plague  provisionally.  If  during  the  epidemic  of 
plague  there  is  also  a  prevalence  of  influenza,  some  of  the  latter  cases 
Influenza  and  '^^^J  resemble  so  closely  plague  cases  without  buboes,  that 
plague.  even  the  most   experienced  physician  may  be   unable  to 

differentiate  the  one  from  the  other,  and  the  diagnosis  has  to  depend 
on  the  bacteriological  examination  of  the  sputum  and  the  blood.  The 
possibility  of  the  two  diseases  occurring  together  in  the  same  patient  is 
not  to  be  overlooked. 

The  tonsillar  variet}'  of  plague  which  is  generally  associated  with 
Tonsiiius  buboes  in  the  neck   may  be  mistaken  for  diphtheria,  as 

plague.  ^y;^g  ^\^Q  pr^gy  jjj  Bombay.    The  bacteriological  examination 

of  the  sputum  and  of  the  exudative  coating  on  the  tonsils  will  readily 
differentiate  the  diseases.  If  plague  bacilli  are  not  found  in  these 
materials,  puncture  of  the  enlarged  gland  or  bubo,  and  examination  of 
its  contents  will  be  necessary. 

In  the  pustular  variety  of  the  disease  plague  bacilli  are  generally 
found  in  the  pustules,  but  care  has  to  be  taken  that  the  plague 
microbes  are  not  overlooked  as  they  are  sometimes  present  in  these  skin 
eruptions  in  the  atypical  or  degenerative  forms. 

Plague  has  been  mistaken  for  malaria,  typhoid,  and  typhus  fever, 
typhlitis,  meningitis,  pneumonia,  diphtheria,  influenza,  relapsing  fever, 
syphilis  and  filariasis  with  enlarged  glands.  It  has  occurred  in  con- 
junction with  most  of  these,  so  that  the  discovery  of  the  special 
micro-organism,  if  any,  of  these  diseases,  does  not  exclude  plague  unless 
the  microbe  of  plague  has  also  been  searched  for  and  not  found. 

The    prognosis  of   plague    in    a   particular   individual   depends   on 

a  number  of  circumstances,  such  as  the  race  and  age  of 
Prognosis.  .  ,  ,      ° 

the    person  attacked,  the   period    of  the   epidemic  when 

attacked,  the  variety  of  plague,  and  the  degree  of  reaction  which  the 

patient    manifests   against    the    disease.     In    the  existing  epidemic  a 

white  person  always  has  a  better  chance  of  recovery  than  a  coloured 


CH.  XV] 


Diagnosis  and  Proffuosis 


313 


person.  Taking  general  averages  it  may  be  stated  that  of  white  people 
attacked  two-thirds  recover,  while  of  coloured  people  attacked  two- 
thirds  die.  Children  between  5  and  10  years  of  age  usually  have 
the  lowest  mortality,  and  persons  attacked  during  the  decline  of  an 
epidemic  have  a  greater  chance  of  recovery  than  those  attacked  when 
the  epidemic  is  on  the  increase.  The  variety  of  plague  also  makes  a 
difference.  Pneumonic  plague  is  very  serious  and  generally  ends  fatally. 
Septicaemic  plague  is  also  of  a  very  grave  character  and  the  prognosis 
is  most  unfavourable.  In  the  bubonic  type  the  situation  of  the  buboes 
exercises  an  influence  on  the  gravity  of  the  illness.  Axillary  buboes 
have  the  highest  mortality,  femoral  and  iliac  the  next,  and  cervical  the 
next.  The  order  of  the  three  latter  may  be  reversed.  Dr  Choksy^ 
analysing  9500  cases  treated  in  Bombay  gives  the  subjoined  relative 
mortality  according  to  (a)  the  type  of  the  disease,  and  (6)  the  situation 
of  the  bubo  in  lyicomplicated  bubonic  cases. 


(a) 


Simple  Bubonic  Plague 
Septicaemic  Plague    ... 
Pneumonic  Plague 
Cellulo-cutaneous  Plague 


Axillary 

Cervical 

Inguinal 

Multiple 

Femoral 

Other  situations 

Parotid  ... 


(6) 


Mortality 

77-25% 
89-62 
96-69 
62-00 

Mortality 

81-29  "/o 

78-87 

77-62 

75-87 

72-56 

71-42 

70-34 


Major  W.  E.  Jennings-  gives  a  detailed  analysis  of  16,132  bubonic 
cases  and  the  regional  case  mortality.     They  are  as  follows : — 

Cases  Mortality 

1712  78-0  7o 

1866    '  77-1 

2429 
2539 
1922 
1988 
1006 
2207 
463 


Left  axillary... 
Eight  axillary 
Left  femoral 
Right  femoral 
Left  inguinal 
Eight  inguinal 
Cervical 
Multiple 
Parotid 


The  Treatment  of  Plaijue  bij  Pro/ 


75-4 
72-3 
71-7 
70-1 
70-5 
70-0 
68-6 


fesnor  l^ustig'x  Serum.     By  N.  H.  Choksy,  M.D. 
2  A   Manual   of  Plaijuc.     By  W.  E.   Jennings,   M.B.,    CM.,    Major   Indian    Medical 
Service,  1903. 


314  Plague  in  the  Indk'idual  [part  hi 

Of  cases  admitted  into  the  Paivl  Hospital,  during  the  Bombay 
epidemic  of  1890-97,  Major  G.  S.  Thomson,  I.M.S.,  gives  the  following 
details^ : — 

Mortality  Men  Women  fliildren  Boys  Girls 

64-5  »/„  C8-6%  71 7o  ^S-S'/o  ^2-5  »/o  Gl-SO/o 

Situation  MorUlity 

of  bubo  Total  Percentage  Males         Females  Died        Recovered      percentage 

Eight  axilla  47  loo  30  17  34  13  72-4 

Left  axilla  32  10  o  IG  16  24  8  75 

Right  femoral  ol)  19-6  45  14  33  26  56 

Left  femoral  31  10-2  18  13  14  17  45-2 

Eight  inguinal  17  5  6  11  6  10  7  59 

Left  inguinal  32  10 -5  25  7  21  11  65-6 

Eight  cervical  8  2-6  7  1  6  2  75 

Left  cervical  4  13  2  2  2  2  50 

Eight  parotid  7  2-3  3  4  5  2  71-4 

Left  parotid  1  0  3  1  —  —  1  — 

Multiple  24  7-9  15  9  14  10  58-3 

No  buboes  42  13-8  29  13  33  9  78-6 

The  utmost  circumspection  has  to  be  exercised  in  giving  an  opinion 
Caution  as  ^^  ^^^  future  course  of  the  illness  as  there  is  no  disease  so 

to  prognosis.  deceptive  and  so  likely  to  mislead  the  physician.  Patients, 
who  to  all  appearances  are  in  a  state  of  convalescence  or  whose  symptoms 
are  mild  and  augur  a  speedy  recovery,  may  suddenly  die  of  heart  failure 
with  or  Avithout  some  slight  exertion  in  getting  out  of  bed,  or  they  may 
suddenly  develop  secondary  infection  of  other  glands  or  organs,  or  fall 
into  an  apathetic  or  marasmic  condition ;  or  patients  with  the  gravest 
of  symptoms  whose  condition  seems  hopeless  may  suddenly  and  un- 
expectedly improve  and  rapidly  convalesce.  A  good  pulse  not  more 
than  120  or  130  per  minute  in  the  acute  stage,  absence  of  acute  cerebral 
disturbance,  or  of  dyspnoea,  and  a  rapid  development  of  the  bubo  with- 
out extensive  infiltration  are  collectively  favourable  signs ;  so  is  absence 
Favourable  ^^  albumen  from  the  urine  and  presence  of  chlorides ;  also 
sigiis.  constipation  or  a  few  loose  motions  a  day  Avithout  diarrhoea. 

Suppuration  of  the  bubo  is  also  favourable,  as  it  indicates  that  the 
patient  has  successfully  passed  through  the  first  (j  or  7  days,  which  is 
the  most  dangerous  period.  In  Hongkong  Wilm  showed  that  75  "/o  of 
the  deaths  occurred  within  the  first  6  days,  and  this  may  be  taken  as  the 
general  rule. 

1  A  Treatise  on  Plague.     By  Major  George  S.  Thomson  and  Dr  John  Thomson,  1901. 


CH.  xv]  Diagnosis  and  Prognosis  315 

Among  unfavourable  signs  are  great  frequency  of  the  pulse  and 
Unfavourable  respiration  from  the  commencement  of  the  illness ;  high 
si&iis.  temperature  which  continues  or  a  sudden  fall  of  tempera- 

ture with  collapse  ;  or  a  secondary  rise  which  is  much  higher  than 
the  primary ;  continued  insomnia ;  early  and  violent  delirium ;  sub- 
sidence of  the  bubo  within  the  first  4  or  5  days,  or  sudden  and  ex- 
tensive infiltration  around  the  bubo ;  severe  vomiting  or  continuous 
diarrho